Difference between revisions of "Medicare (United States)" - New World Encyclopedia

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:''This article refers to '''Medicare''', a United States health insurance program. For similarly named programs in other countries, see [[Medicare]]''.
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:''This article refers to '''Medicare,''' a United States [[health insurance]] program. For similarly named programs in other countries, see [[Medicare]]''.
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[[Image:Lyndon Johnson signing Medicare bill, with Harry Truman, 30 July, 1965.jpg|thumb|250px|President Johnson signing the Medicare amendment. [[Harry S. Truman|Harry Truman]] and his wife, [[Bess Truman|Bess]], are on the far right]]
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[[Image:Lyndon Johnson signing Medicare bill, with Harry Truman, 30 July, 1965.jpg|thumb|275px|President Johnson signing the Medicare amendment. [[Harry S. Truman|Harry Truman]] and his wife, [[Bess Truman|Bess]], are on the far right]]
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Medicare is a federally funded social insurance program designed to cover individuals 65 years of age or older, or those who meet other special criteria. In general, Medicare is available to U.S. citizens or to permanent legal residents having at least 5 consecutive years of residence in the United States, who are also 65 years or older. Individuals who are under 65 and meet the citizenship or residency requirements may also be eligible for Medicare if they are disabled and receive other forms of assistance such as Social Security or Social Security Disability Insurance for a minimum of 24 months. Medicare, unlike Medicaid, is based on medical necessity as opposed to medical necessity coupled with financial need. Medicare provides insurance benefits in several different areas: Hospital insurance, Medical insurance, Private Health Insurance supplementation, and Prescription drug coverage. Throughout its history, Medicare has experienced and continues to experience steady increases in spending due to challenges such as a growing aged population of beneficiaries, questions of financial feasibility, as well as waste and fraud concerns. Increases in health care costs also play a part in Medicare’s percentage increase in the federal budget. Despite fiscal spending and budget concerns surrounding Medicare, the program continues to serve as a large scale comprehensive social insurance option for qualified elderly and/or disabled citizens and permanent residents who are no longer able to work, but rate quality health care as a result of a lifetime of service.  
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'''Medicare''' is a federally funded [[health insurance]] program in the [[United States]], designed to cover older individuals and those who meet other special criteria. In general, Medicare is available to U.S. citizens, or permanent legal residents having at least five consecutive years of residence in the United States, who are 65 years or older. Individuals who are under 65 and meet the citizenship or residency requirements may be eligible for Medicare if they are [[disability|disabled]] and have received other forms of assistance such as [[Social Security]] or [[Social Security Disability Insurance]] for a minimum of 24 months.
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Medicare is an [[entitlement program]] and not based on financial need. American citizens are automatically eligible for Medicare upon reaching the age of 65 because they, or their spouses, paid Social Security [[tax]]es during their working years. Medicare is very different from [[Medicaid]], a government assistance program that provides health care benefits to certain categories of low-income individuals, although they are often associated. Unlike Medicaid, which is jointly funded by federal and state governments and has eligibility criteria which vary from state to state, Medicare is fully funded by the federal government and its criteria are consistent nationwide.
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Medicare provides insurance benefits in several different areas including [[hospital]] stays, post-hospital skilled [[nursing]] care, and [[prescription drug]] coverage. There are gaps in its coverage, however, which individuals may elect to cover through private "Medigap" insurance plans, or, if they are eligible, Medicaid. Throughout its history, Medicare has experienced and continues to experience steady increases in spending due to challenges such as a growing aged population, concerns about waste and [[fraud]], and increases in health care costs, which have led to projections of financial insolvency. For a society that values the contributions made by its population during their working life, Medicare is a significant [[social welfare]] program and efforts continue to be made to improve the program and solve its problems.  
  
 
==Introduction==
 
==Introduction==
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'''Medicare''' is a [[Social insurance|social insurance]] program administered by the [[United States government]], providing [[health insurance]] coverage to people who are aged 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965, by President [[Lyndon B. Johnson]] as amendments to [[Social Security (United States)|Social Security]] legislation. At the bill-signing ceremony President Johnson enrolled former President [[Harry S. Truman]] as the first Medicare beneficiary and presented him with the first Medicare card.<ref>Social Security Online, [http://www.ssa.gov/history/lbjsm.html Medicare Is Signed Into Law]. Social Security History, Social Security Online. Retrieved November 29, 2008.</ref>  
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'''Medicare''' is a [[Social insurance|social insurance]] program administered by the [[United States]] [[government]] providing [[health insurance]] coverage to people who are aged 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965, by President [[Lyndon B. Johnson]] as amendments to [[Social Security]] legislation. At the bill-signing ceremony President Johnson enrolled former President [[Harry S. Truman]] as the first Medicare beneficiary and presented him with the first Medicare card.<ref>Social Security Online, [http://www.ssa.gov/history/lbjsm.html Medicare Is Signed Into Law,] Social Security History, Social Security Online. Retrieved August 31, 2020.</ref> In 1973, Medicare was expanded to cover people under the age of 65 who needed [[dialysis]] or [[organ transplant|transplants]] due to [[kidney]] failure, as well as those with specific [[disability|disabilities]].
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The [[Centers for Medicare and Medicaid Services]] (CMS), a component of the [[Department of Health and Human Services]] (HHS), administers Medicare, [[Medicaid]], the [[State Children's Health Insurance Program]] (SCHIP), and the [[Clinical Laboratory Improvement Amendments]] (CLIA). Along with the [[United States Department of Labor|Departments of Labor]] and [[United States Department of the Treasury|Treasury]], CMS also implements the insurance reform provisions of the [[Health Insurance Portability and Accountability Act]] of 1996 (HIPAA). The [[Social Security Administration]] is responsible for determining Medicare eligibility and processing premium payments for the Medicare program.
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Initially, Medicare was administered by the [[Social Security Administration]]. In 1977, it was transferred to the [[Department of Health and Human Services]] (DHHS). The [[Centers for Medicare and Medicaid Services]] (CMS), a department of DHHS, administers Medicare, [[Medicaid]], the [[State Children's Health Insurance Program]] (SCHIP), and the [[Clinical Laboratory Improvement Amendments]] (CLIA). The Social Security Administration continues to be responsible for determining Medicare eligibility and processing premium payments for the Medicare program. Since Medicare is a federal program, the rules for eligibility, coverage, and costs are constant throughout the nation.
  
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Medicare is partially financed by [[payroll tax]]es imposed by the [[Federal Insurance Contributions Act tax|Federal Insurance Contributions Act]] (FICA) and the [[Social Security Act#Social Security tax on wages and self-employment income|Self-Employment Contributions Act]] of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount of wages, etc., on which the Medicare tax could be imposed each year. Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the entire 2.9% tax of self employed net earnings must be paid by the self-employed individual, however half of the tax can be deducted from the income calculated for [[income tax]] purposes.
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Medicare is partially financed by [[payroll tax]]es imposed by the [[Federal Insurance Contributions Act tax|Federal Insurance Contributions Act]] (FICA) and the [[Self-Employment Contributions Act]] of 1954. In the case of employees, the tax is equal to 2.9 percent (1.45 percent withheld from the worker and a matching 1.45 percent paid by the employer) of the [[wages]], [[salaries]], and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount on which the Medicare tax could be imposed each year. Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the entire 2.9 percent tax of self employed net earnings must be paid by the self-employed individual, however half of the tax can be deducted from the income calculated for [[income tax]] purposes.
  
 
== Eligibility ==
 
== Eligibility ==
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In general, individuals are eligible for Medicare if they are a U.S. citizen or have been a permanent legal resident for five continuous years, '''and''' they are 65 years or older, '''or''' they are under 65, disabled and have been receiving either [[Social Security]] or the [[Railroad Retirement Board]] disability benefits for at least 24 months, '''or''' they get continuing [[dialysis]] for [[end stage renal disease|permanent kidney failure]] or need a kidney transplant, '''or''' they are eligible for [[Social Security Disability Insurance]] and have [[amyotrophic lateral sclerosis]] (ALS-Lou Gehrig's disease).  
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In general, individuals are eligible for Medicare if they are a U.S. citizen or have been a permanent legal resident for 5 continuous years, '''and''' they are 65 years or older, '''or''' they are under 65, disabled and have been receiving either [[Social Security (United States)|Social Security]] or the [[Railroad Retirement Board]] disability benefits for at least 24 months, '''or''' they get continuing dialysis for [[end stage renal disease|permanent kidney failure]] or need a kidney transplant, '''or''' they are eligible for [[Social Security Disability Insurance]] and have [[amyotrophic lateral sclerosis|Amyotrophic Lateral Sclerosis]] (ALS-Lou Gehrig's disease).  
 
  
 
Many beneficiaries are [[Medicare dual eligible|dual-eligible]]. This means they qualify for both Medicare and [[Medicaid]]. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay any drugs that are not covered by Part D.
 
Many beneficiaries are [[Medicare dual eligible|dual-eligible]]. This means they qualify for both Medicare and [[Medicaid]]. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay any drugs that are not covered by Part D.
  
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In 2007, Medicare provided health care coverage for 43 million Americans. Enrollment is expected to reach 77 million by 2031, when the [[Post-World War II baby boom|baby boom]] generation is fully enrolled.<ref>Trustees Report & Trust Funds, [http://www.cms.hhs.gov/ReportsTrustFunds Overview] Trustees Report & Trust Funds Overview, Centers for Medicare and Medicaid Services, 2008. Retrieved November 29, 2008.</ref>
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In 2019, Medicare provided health care coverage for over 60 million Americans. Enrollment is expected to reach 77 million by 2031, when the [[Post-World War II baby boom|baby boom]] generation is fully enrolled.<ref>[https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/ Trustees Report & Trust Funds] ''Centers for Medicare and Medicaid Services'', 2008. Retrieved August 31, 2020.</ref>
  
 
== Benefits ==
 
== Benefits ==
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[[Image:Medicare.jpg|thumb|right|A Medicare card, with several areas of the card obscured to protect privacy.<br/> There are separate lines with for Part A and Part B, each with its own date.<br/> There is no lines for Part C or D, as a separate card is issued for those benefits by the private insurance company.]]
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[[Image:Medicare.jpg|thumb|right|250px|A Medicare card, with several areas of the card obscured to protect privacy.<br/> There are separate lines for Parts A and B, each with its own date.<br/> There are no lines for Parts C or D, as a separate card is issued for those benefits by the private insurance company.]]
  
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The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where [[prescription drug]]s are covered by original Medicare, but as of January 2006, [[Medicare Part D]] provides more comprehensive drug coverage. Medicare Advantage plans are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to [[medical necessity]].
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The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where [[prescription drug]]s are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Part C or Medicare Advantage plans are another way for beneficiaries to receive their Part A, B, and D benefits.  
  
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=== Part A: Hospital Insurance ===  
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=== Part A: Hospital insurance ===  
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Most individuals automatically enroll in Medicare Part A without having to pay a premium because they, or their spouse, paid sufficient [[tax]]es while working.
  
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Part A covers [[hospital]] stays (including stays in a skilled nursing facility) if certain criteria are met:
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Medicare Part A covers [[hospital]] stays and certain services following a hospital stay. These include stays in a skilled [[nursing]] facility, such as a [[nursing home]] or [[hospice]] care for terminally ill patients, and treatment received there, such as [[physical therapy]].
  
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# The hospital stay must be at least three days, three midnights, not counting the discharge date.
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=== Part B: Medical insurance ===
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# The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. For instance, a hospital stay for a broken hip and then a nursing home stay for physical therapy would be covered.
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Medicare Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10 percent per year) imposed for not enrolling in Part B unless actively working. There is a monthly premium charged for Part B insurance.
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# If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered.
 
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# The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or [[long-term care]] activities, including [[activities of daily living]] (ADLs) such as personal hygiene, cooking, cleaning, etc.
 
  
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The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2008, $128.00 per day). Many [[insurance]] companies have a provision for skilled nursing care in the policies they sell.
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Part B coverage includes physician and nursing services, [[Medical radiography|x-rays]], laboratory and diagnostic tests, [[influenza]] and [[pneumonia]] [[vaccination]]s, [[blood transfusion]]s, renal [[dialysis]], [[Outpatient surgery|outpatient hospital procedures]], limited [[ambulance]] transportation, [[immunosuppressive drug]]s for [[organ transplant]] recipients, [[chemotherapy]], hormonal treatments such as lupron, and other outpatient medical treatments administered in a doctor's office. Medication administration is covered under Part B only if it is administered by the physician during an office visit.
  
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If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period.
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Part B also helps with [[durable medical equipment]] (DME), including [[cane]]s, walkers, [[wheelchair]]s, and [[mobility scooter]]s for those with [[mobility impairment]]s. [[Prosthesis|Prosthetic devices]] such as [[artificial limb]]s and [[breast prosthesis]] following [[mastectomy]], as well as one pair of [[eyeglasses]] following [[cataract surgery]], and [[oxygen therapy|oxygen]] for home use is also covered.
  
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=== Part B: Medical Insurance ===
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=== Part C: Medicare advantage plans ===
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With the passage of the [[Balanced Budget Act of 1997]], Medicare beneficiaries were given the option to receive their Medicare benefits through private [[health insurance]] plans, instead of through the original Medicare plan (Parts A and B). These programs were known as "[[Medicare+Choice]]" or "Part C" plans. In 2000, almost 16 percent of all Medicare beneficiaries participated in "Medicare+Choice" plans.<ref name=Moon>Marilyn Moon, ''Medicare: A Policy Primer'' (Urban Institute Press, 2006, ISBN 978-0877667537).</ref> This use of such plans has moved Medicare away from its original role as the insurer to a role as purchaser of health insurance.
  
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Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10 percent per year) imposed for not enrolling in Part B unless actively working.
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Pursuant to the [[Medicare Prescription Drug, Improvement, and Modernization Act]] of 2003, the compensation and business practices changed for insurers that offer these plans, and "Medicare+Choice" plans became known as "Medicare Advantage" (MA) plans. Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MAPD.
  
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Part B coverage includes physician and nursing services, [[Medical radiography|x-rays]], laboratory and diagnostic tests, influenza and pneumonia vaccinations, [[blood transfusion]]s, renal [[dialysis]], [[Outpatient surgery|outpatient hospital procedures]], limited ambulance transportation, [[Immunosuppressive drug]]s for [[organ transplant]] recipients, [[chemotherapy]], hormonal treatments such as lupron, and other outpatient medical treatments administered in a doctor's office. Medication administration is covered under Part B only if it is administered by the physician during an office visit.
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=== Part D: Prescription drug plans ===
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Medicare Part D went into effect on January 1, 2006, by the passage of the [[Medicare Prescription Drug, Improvement, and Modernization Act]]. Anyone with Part A or B is eligible for Part D. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover them, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to drugs used to treat anorexia, weight loss, or weight gain, fertility drugs, drugs to treat erectile dysfunction, drugs only for the relief of non-prescription drugs.<ref>[https://www.medicareinteractive.org/get-answers/medicare-prescription-drug-coverage-part-d/medicare-part-d-coverage/drugs-excluded-from-part-d-coverage Drugs excluded from Part D coverage] ''Medicare Interactive''. Retrieved August 31, 2020.</ref>
  
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Part B also helps with [[durable medical equipment]] (DME), including [[cane]]s, walkers, [[wheelchair]]s, and [[mobility scooter]]s for those with [[mobility impairment]]s. [[Prosthesis|Prosthetic devices]] such as [[artificial limb]]s and [[breast prosthesis]] following [[mastectomy]], as well as one pair of [[eyeglasses]] following [[cataract surgery]], and [[oxygen therapy|oxygen]] for home use is also covered.<ref>University of Iowa Health Care, [http://www.uihealthcare.com/topics/aging/agin3390.html Medicare: Part A & B], University of Iowa Hospitals and Clinics, 2005. Retrieved November 29, 2008.</ref>
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=== Medicare supplement (Medigap) policies ===
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{{main|Medigap}}
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=== Part C: Medicare Advantage plans ===
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Medicare Part A and Part B together do not cover all the medical services that individuals require. Also, there are many [[health insurance]] plans offering greater coverage that are available to younger individuals. This gap in coverage led to options for additional insurance for Medicare enrollees.
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With the passage of the [[Balanced Budget Act of 1997]], Medicare beneficiaries were given the option to receive their Medicare benefits through private [[health insurance]] plans, instead of through the original Medicare plan (Parts A and B). These programs were known as "[[Medicare+Choice]]" or "Part C" plans. Pursuant to the [[Medicare Prescription Drug, Improvement, and Modernization Act]] of 2003, the compensation and business practices changed for insurers that offer these plans, and "Medicare+Choice" plans became known as "Medicare Advantage" (MA) plans.
 
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Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare private health plan, Medicare pays the private health plan a set amount every month for each member. Members may have to pay a monthly premium in addition to the Medicare Part B premium and generally pay a fixed amount (a copayment of $20, for example) every time they see a doctor. The copayment can be higher to see a specialist.
 
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The private plans are required to offer a benefit “package” that is at least as good as Medicare’s and cover everything Medicare covers, but they do not have to cover every benefit in the same way. Plans that pay less than Medicare for some benefits, like skilled nursing facility care, can balance their benefits package by offering lower copayments for doctor visits. Private plans use some of the excess payments they receive from the government for each enrollee to offer supplemental benefits. Some plans put a limit on their members’ annual out-of-pocket spending on medical care, providing some insurance against catastrophic costs over $5,000, for example. But many plans use the excess subsidies to offer dental coverage and other services not covered by Medicare and can leave members exposed to high medical bills if they fall seriously ill. Private plan members can end up with unexpectedly high out-of-pocket costs.
 
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In 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.<ref>Mark Merlis, [http://www.kff.org/medicare/upload/7744.pdf "The Value of Extra Benefits Offered by Medicare Advantage Plans in 2006,"] The Kaiser Family Foundation, January 2008. Retrieved November 29, 2008.</ref>
 
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Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MAPD.
 
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=== Part D: Prescription Drug plans ===
 
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{{main|Medicare Part D}}
 
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[[Medicare Part D]] went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the [[Medicare Prescription Drug, Improvement, and Modernization Act]]. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to [[benzodiazepine]]s, [[cough suppressant]] and [[barbiturate]]s.<ref>Product/Drug/Drug Category, [http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PartDDrugsPartDExcludedDrugs_04.19.06.pdf Part D Drugs/Part D Excluded Drugs]. Centers for Medicare and Medicaid Services, 2006. Retrieved November 29, 2008.</ref> Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.<ref>Office of Inspector General, [http://oig.hhs.gov/oas/reports/region6/60600022.pdf Report on the Medicare Drug Discount Card Program Sponsor McKesson Health Solutions] Department of Health and Human Services, 2006. Retrieved November 29, 2008.</ref>
 
  
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It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as [[benzodiazepine]]s, and other restricted controlled substances.
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Some individuals with limited financial resources qualify for [[Medicaid]], which covers many of the services not covered by Medicare. Others, who do not qualify for Medicaid, may elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill the gap in their needs for medical coverage. These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006, are prohibited from covering drugs.
  
 
== Out-of-pocket costs ==
 
== Out-of-pocket costs ==
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Neither Part A nor Part B pays for all of a covered person's medical costs. The program contains [[insurance premium|premium]]s, [[deductible]]s and coinsurance, which the covered individual must [[out-of-pocket expenses|pay out-of-pocket]]. Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare.  
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Neither Medicare Part A nor Part B pays for all of a covered person's medical costs. The program contains [[insurance premium|premium]]s, [[deductible]]s, and coinsurance, which the covered individual must [[out-of-pocket expenses|pay out-of-pocket]]. Some people may qualify to have other governmental programs (such as [[Medicaid]]) pay premiums and some or all of the costs associated with Medicare.  
  
 
=== Premiums ===
 
=== Premiums ===
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Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more quarters in which they paid [[Federal Insurance Contributions Act]] taxes. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may purchase Part A for a monthly premium of:
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Most Medicare enrollees do not pay a monthly Part A premium, because they (or their spouse) have had 40 or more quarters in which they paid [[Federal Insurance Contributions Act]] taxes. Only those eligible for Medicare but who do not have 40 or more quarters of Medicare-covered employment are required to pay a monthly premium.
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*$233.00 per month (2008) for those with 30-39 quarters of Medicare-covered employment, or
 
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*$423.00 per month (in 2008) for those with less than 30 quarters of Medicare-covered employment and who are not otherwise eligible for premium-free Part A coverage.
 
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All Medicare Part B enrollees pay an [[insurance premium]] for this coverage; the standard Part B premium for 2008 is $96.40 per month. A new income-based premium [[schema]] has been in effect for 2007, wherein Part B premiums are higher for beneficiaries with incomes exceeding $80,000 for individuals or $160,000 for married couples. Depending on the extent to which beneficiary earnings exceed the base income, these higher Part B premiums are $122.20, $160.90, $199.70, or $238.40 for 2008, with the highest premium paid by individuals earning more than $205,000, or married couples earning more than $410,000.<ref name="2008 Medicare & You">Centers for Medicare & Medicaid Services, [http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf Medicare & You handbook, 2008] Centers for Medicare & Medicaid Services, 2008. Retrieved November 29, 2008.</ref> In September of 2008, [[Centers for Medicare and Medicaid Services|CMS]] announced that Part B premiums would be unchanged  ($96.40 per month) in 2009 for 95 percent of Medicare beneficiaries. This would be only the sixth year without a premium increase since Medicare was established in 1965.<ref>Victoria Colliver, [http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/09/20/BU1O131A2F.DTL&hw=medicare+premiums&sn=001&sc=1000 "For most, Medicare premiums won't rise in 2009,"] ''San Francisco Chronicle'', September 20, 2008. Retrieved November 29, 2008.</ref>
 
  
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Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks.
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All Medicare Part B enrollees pay an [[insurance premium]] for this coverage. Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly [[Social Security]] checks.
  
 
Part C and D plans may or may not charge premiums, at the programs' discretion. Part C plans may also choose to rebate a portion of the Part B premium to the member.
 
Part C and D plans may or may not charge premiums, at the programs' discretion. Part C plans may also choose to rebate a portion of the Part B premium to the member.
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''Italic text''
 
  
 
=== Deductible and coinsurance ===
 
=== Deductible and coinsurance ===
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Both Medicare Parts A and B have annual or benefit period (episode of illness) deductibles and coinsurance charges that must be paid for covered services. These are standard amounts for all individuals, although they may change from year to year.
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'''Part A''' &mdash; For each [[benefit period]], a beneficiary will pay:
 
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* A Part A deductible of $1,024 (in 2008) for a hospital stay of 1-60 days.
 
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* A $256 per day co-pay (in 2008) for days 61-90 of a hospital stay.
 
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* A $512 per day co-pay (in 2008) for days 91-150 of a hospital stay, as part of their limited [[Lifetime Reserve Days]].
 
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* All costs for each day beyond 150 days<ref name="2008 Medicare & You"/>
 
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* Coinsurance for a Skilled Nursing Facility is $128.00 per day (in 2008) for days 21 through 100 for each benefit period.
 
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* A blood deductible of the first 3 pints of blood needed in a calendar year, unless replaced. There is a 3 pint blood deductible for both Part A and Part B, and these separate deductibles do not overlap.
 
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'''Part B''' &mdash; After a beneficiary meets the yearly deductible of $135.00 (in 2008), they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B. They are also required to pay an excess charge of 15% for services rendered by non-participating Medicare providers.
 
  
 
The deductibles and coinsurance charges for Part C and D plans vary from plan to plan.
 
The deductibles and coinsurance charges for Part C and D plans vary from plan to plan.
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=== Medicare supplement (Medigap) policies ===
 
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{{main|Medigap}}
 
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Some people elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill in the holes in Original Medicare (Part A and B). These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs.
 
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Some have suggested that by reducing the cost-sharing requirements in the Medicare program, Medigap policies increase the use of health care by Medicare beneficiaries and thus increase Medicare spending. One recent study suggests that this concern may have been overstated due to methodological problems in prior research.<ref> Jeff Lemieux, Teresa Chovan, and Karen Heath, [http://content.healthaffairs.org/cgi/content/abstract/27/2/469 "Medigap Coverage And Medicare Spending: A Second Look,"] ''Health Affairs'' 27(2) (2008): 469-477. Retrieved November 29, 2008.</ref>
 
  
 
== Costs and funding challenges ==
 
== Costs and funding challenges ==
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[[Image:Medicare and Medicaid GDP Chart.png|thumb|300px|Medicare and Medicaid Spending as percentage of GDP.]]
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[[Image:Medicare and Medicaid GDP Chart.png|thumb|400px|Medicare and Medicaid Spending as % GDP]]
 
 
As an expansive social insurance program, Medicare often faces funding challenges such as long-term financial viability, the aging population at large, as well as waste and fraud.  
 
As an expansive social insurance program, Medicare often faces funding challenges such as long-term financial viability, the aging population at large, as well as waste and fraud.  
 
According to the 2004 "Green Book" of the [[House Ways and Means Committee]], Medicare expenditures from the American government were $256.8 billion in fiscal year 2002. Beneficiary premiums are highly subsidized, and net outlays for the program, accounting for the premiums paid by subscribers, were $230.9 billion.
 
According to the 2004 "Green Book" of the [[House Ways and Means Committee]], Medicare expenditures from the American government were $256.8 billion in fiscal year 2002. Beneficiary premiums are highly subsidized, and net outlays for the program, accounting for the premiums paid by subscribers, were $230.9 billion.
  
−
Medicare spending is growing steadily in both absolute terms and as a percentage of the [[United States federal budget|federal budget]]. Total Medicare spending reached $440 billion for [[fiscal year]] 2007, or 16 percent of all federal spending. The only larger categories of federal spending are Social Security and [[United States Department of Defense|defense]]. Given the current pattern of spending growth, maintaining Medicare's financing over the long-term may well require significant changes.<ref name="Potetz 2008">Lisa Potetz, [http://www.kff.org/medicare/upload/7731.pdf "Financing Medicare: an Issue Brief,"] Kaiser Family Foundation, January 2008. Retrieved November 29, 2008.</ref>
+
These expenditures are increasing, both in absolute terms and as a percentage of the [[United States federal budget|federal budget]]. Total Medicare spending reached $440 billion for [[fiscal year]] 2007, or 16 percent of all federal spending. The only larger categories of federal spending were [[Social Security]] and [[United States Department of Defense|defense]].  
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According to the 2008 report by the board of trustees for Medicare and Social Security, Medicare spends more than it brings in from taxes, with the result that The Medicare hospital insurance trust fund was projected to become insolvent in a decade.<ref>California Healthline, [http://www.californiahealthline.org/articles/2008/3/26/Annual-Federal-Report-Forecasts-Medicare-Funding-Gap-by-2019.aspx?topicID=37 Annual Federal Report Forecasts Medicare Funding Gap by 2019] California Healthcare Foundation, 2008. Retrieved November 30, 2008.</ref><ref>The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, [http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2008.pdf 2008 Annual Report of the Boards of Trustees of the Federal Hospital and Federal Supplementary Medical Insurance Trust Funds] Centers for Medicare and Medicaid Services, March 25, 2008. Retrieved December 4, 2008.</ref><ref name="beyond actuarial balance 2008">American Academy of Actuaries, [http://www.actuary.org/pdf/medicare/trustees_08.pdf "Medicare’s Financial Condition: Beyond Actuarial Balance,"] American Academy of Actuaries, March 2008. Retrieved December 4, 2008.</ref><ref name="Potetz 2008"/>  Shortly after the release of the report, the [[Office_of_the_Chief_Actuary#United_States_Government|Chief Actuary]] testified that the insolvency of the system could be pushed back by 18 months if Medicare Advantage plans were paid at the same rate as the traditional fee-for-service program. He also testified that the 10-year cost of Medicare drug benefit is 37% lower than originally projected in 2003, and 17% percent lower than last year's projections.<ref>Kaiser Family Foundation, [http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=51311 Kaiser Daily Health Policy Report] Daily Reports, Kaiser Family Foundation, April 02, 2008. Retrieved December 4, 2008.</ref>
 
−
 
 
−
Spending on Medicare and Medicaid is projected to grow dramatically in coming decades. While the same demographic trends that affect Social Security also affect Medicare, rapidly rising medical prices appear a more important cause of projected spending increases. The [[Congressional Budget Office]] (CBO) has indicated that: "Future growth in spending per beneficiary for Medicare and Medicaid—the federal government’s major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation’s central long-term challenge in setting federal fiscal policy."  Further, the CBO also projects that "total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population."<ref>Peter R. Orszag, [http://www.cbo.gov/ftpdocs/93xx/doc9385/06-17-LTBO_Testimony.pdf The Long-Term Budget Outlook and Options for Slowing the Growth of Health Care Costs]Congressional Budget Office Statement before the Committee on Finance United States Senate, June 17, 2008. Retrieved December 4, 2008.</ref>
 
  
−
Another segment of the cost of Medicare is attributable to [[fraud]], which government auditors estimate costs Medicare billions of dollars a year.<ref>U.S. Government Accountability Office, [http://www.gao.gov/docdblite/summary.php?rptno=GAO-05-656&accno=A37738 Medicare: More Effective Screening and Stronger Enrollment Standards Needed for Medical Equipment Suppliers] GAO, September 22, 2005. Retrieved December 4, 2008.</ref><ref>United States General Accounting Office [http://www.gao.gov/new.items/d02546.pdf Medicare Fraud and Abuse: DOJ Continues to Promote Compliance with False Claims Act Guidance], GAO Report to Congressional Committees, April 2002. Retrieved December 4, 2008.</ref> The [[Government Accountability Office]] lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.<ref name=2006report>The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, [http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2006.pdf 2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds] Centers for Medicare and Medicaid Services, May 1, 2006. Retrieved December 5, 2008. </ref> A [[Washington Post]] story from June of 2008 reported that Medicare fraud is a growing problem. Limited resources mean that fewer than 5% of Medicare claims are audited. The annual cost to taxpayers of Medicare fraud is estimated to be over $60 billion.<ref>Carrie Johnson, [http://www.washingtonpost.com/wp-dyn/content/article/2008/06/12/AR2008061203915.html Medical Fraud a Growing Problem: Medicare Pays Most Claims Without Review], The [[Washington Post]], June 13, 2008. Retrieved December 5, 2008.</ref>
+
Spending on Medicare and Medicaid is projected to continue to grow with the result that the Medicare hospital insurance trust fund has been projected to become insolvent.<ref>[http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2008.pdf 2008 Annual Report of the Boards of Trustees of the Federal Hospital and Federal Supplementary Medical Insurance Trust Funds] Centers for Medicare and Medicaid Services, March 25, 2008. Retrieved August 31, 2020.</ref><ref name="beyond actuarial balance 2008"> [http://www.actuary.org/pdf/medicare/trustees_08.pdf Medicare’s Financial Condition: Beyond Actuarial Balance] American Academy of Actuaries, March 2008. Retrieved August 31, 2020.</ref>
  
−
== Social Concerns ==
+
While the same demographic trends that affect Social Security also affect Medicare, rapidly rising medical prices appear a more important cause of projected spending increases. The [[Congressional Budget Office]] (CBO) has indicated that:
−
Medicare faces continuing challenges dealing with the financial viability, availability, and quality control of services that cause widespread social concerns. In its 2006 annual report to Congress, the Medicare Board of Trustees reported that the program's hospital insurance trust fund could run out of money by 2018. The trustees have made such projections in the past, but this one was bleaker than the outlook reported in 2005.<ref>CMS Office of Public Affairs, [http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1846 2006 Medicare Trustees Report] Centers for Medicare and Medicaid Services, May 01, 2006. Retrieved December 5, 2008.</ref>
+
<blockquote>Future growth in spending per beneficiary for Medicare and Medicaid—the federal government’s major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation’s central long-term challenge in setting federal fiscal policy. …total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population.<ref>Peter R. Orszag, [https://www.cbo.gov/publication/41709 The Long-Term Budget Outlook and Options for Slowing the Growth of Health Care Costs]Congressional Budget Office Statement before the Committee on Finance United States Senate, June 17, 2008. Retrieved August 31, 2020.</ref></blockquote>
  
−
Popular opinion surveys show that the public views Medicare’s problems as serious, but not as urgent as other concerns. In January 2006, the Pew Research Center found 62 percent of the public said addressing Medicare’s financial problems should be a high priority for the government, but that still put it behind other priorities.<ref>Public Agenda for Citizens, [http://www.publicagenda.org/citizen/issueguides/medicare/publicview/people-concerns Medicare: People's Chief Concerns] Issue Guides, Public Agenda for Citizens, December 4, 2008. Retrieved December 5, 2008.</ref> Surveys suggest that there’s no public consensus behind any specific strategy to keep the program solvent.<ref>Public Agenda for Citizens, [http://www.publicagenda.org/citizen/issueguides/medicare/publicview/redflags Medicare: Red Flags] Issue Guides, Public Agenda for Citizens, December 4, 2008. Retrieved December 5, 2008.</ref>
+
Another segment of the cost of Medicare is attributable to [[fraud]], which government auditors estimate costs Medicare billions of dollars a year.<ref> [https://www.gao.gov/products/GAO-05-656 Medicare: More Effective Screening and Stronger Enrollment Standards Needed for Medical Equipment Suppliers] ''U.S. Government Accountability Office'', September 22, 2005. Retrieved August 31, 2020.</ref><ref>[https://www.gao.gov/new.items/d02546.pdf Medicare Fraud and Abuse: DOJ Continues to Promote Compliance with False Claims Act Guidance,] ''GAO Report to Congressional Committees'', April 2002. Retrieved August 31, 2020.</ref> The [[Government Accountability Office]] lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.<ref name=2006report>[http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2006.pdf 2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds] ''Centers for Medicare and Medicaid Services'', May 1, 2006. Retrieved August 31, 2020. </ref>
  
−
===Quality of beneficiary services===
+
== Social concerns and the future of Medicare ==
−
An a 2001 study by the [[Government Accountability Office]] evaluated the quality of responses given by Medicare contractor customer service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%.<ref>Leslie G. Aronovitz, [http://www.gao.gov/new.items/d011141t.pdf Medicare: Improvements Needed in Provider Communications and Contracting Procedures], Testimony Before the Subcommittee on Health, Committee on Ways and Means, House of Representatives, September 25, 2001. Retrieved December 5, 2008.</ref>
+
Medicare is the largest publicly funded [[health insurance]] program in the United States and plays an essential role in caring for the needs of the elderly and disabled. For some, it represents what national health insurance could be in the United States. However, Medicare faces continuing challenges dealing with the financial viability, availability, and quality control of services that cause widespread social concerns.  
  
−
===Hospital accreditation===
+
When it began in the 1960s, Medicare covered approximately 19 million individuals aged over 65. By the beginning of the twenty-first century it had expanded to over 39 million, with the number projected to increase to almost 80 million by 2030.<ref name=Moon/> As a result of the large numbers of individuals involved, its large share of the federal budget, and the rapid rate of its expansion, Medicare has been subjected to much scrutiny and changes and improvements have continually been under discussion. Competing approaches to reform include reducing per capita spending through incremental changes or major structural reforms, such as shifting Medicare to the control of private plans. Incremental approaches generally involve changing payment policies, and have been criticized as focusing on prices charged rather than the amount of use of services.<ref name=Moon/>
−
In most states the [[Joint Commission]], a private, [[non-profit organization]] for accrediting hospitals, possesses a monopoly over whether or not a hospital is able to participate in Medicare, as currently there are no competitor organizations recognized by CMS. An attempt by [[TÜV Healthcare Specialists]] to provide a [[hospital accreditation]] option was denied in 2006. <ref>CMS, [http://www.cms.hhs.gov/QuarterlyProviderUpdates/APR2006/ItemDetail.asp?ItemID=CMS060161 QPU April 2006] Quarterly Provider Updates, Centers for Medicare and Medicaid Services, 04/03/2006. Retrieved December 5, 2008.</ref> Rebecca Wise, CEO of TÜVHS, has said "Choice and competition are the hallmarks of a free market.... Can you think of an industry with a more profound impact on our lives than healthcare? Yet there is a much higher chance of you getting the wrong dosage of medicine in a hospital than there is of a manufacturer putting the wrong chip on a circuit board. It’s a failure of the system not the people." <ref>Med Law, [http://www.medlaw.com/healthlaw/HOSPITAL/6_3/new-competitor-takes-on-j.shtml New Competitor Takes On JCAHO Accreditation] MedLaw.com, December 14, 2005. Retrieved December 5, 2008. </ref>
 
  
−
Beyond hospitals and hospital accreditation, there are now a number of alternative American organizations possessing healthcare-related deeming power for Medicare. These include the [[Community Health Accreditation Program]], the [[Accreditation Commission for Health Care]], [[the Compliance Team]] and the [[Healthcare Quality Association on Accreditation]].
+
As the population ages, the needs for [[healthcare]] for the elderly increase. There are many concerns about financing good quality health care that is appropriate for this segment of the population. One concern is that [[health insurance]] through Medicare will not continue, or not at an affordable price, due to federal budget cuts. Related to this is the concern that funding for Medicare provided by the [[Social Security Administration]] will be exhausted and the program become insolvent before the aging population, particularly [[Baby Boomers]], are old enough to benefit from the taxes they pay.
  
−
===Physician residency ===
+
The fundamental problem is that the ratio of workers paying Medicare taxes to retirees drawing benefits is shrinking at the same time that the price of health care services per person is increasing. From 3.9 workers paying taxes into Medicare for every older American receiving services as the baby boom generation retires, this figure is projected to drop to 2.4 workers for each beneficiary by 2030. However, Medicare spending is expected to grow by about 7 percent per year during that time period. As a result, the financing of the program is out of actuarial balance, presenting serious challenges in both the short-term and long-term.<ref name="beyond actuarial balance 2008"/>
−
Medicare funds the vast majority of [[Residency (medicine)|residency]] training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education payments. Medicare also uses taxes for Indirect Medical Education, a subsidy paid to [[teaching hospital]]s in exchange for training resident physicians.<ref>Scott Gottlieb, [http://findarticles.com/p/articles/mi_m1272/is_n2630_v126/ai_20004039  Medicare funding for medical education: a waste of money?] USA Today (Society for the Advancement of Education), November, 1997. Retrieved December 5, 2008.</ref>  Overall funding levels, however, have remained frozen over the last ten years, creating a bottleneck in the training of new physicians in the US.<ref name=croasdale>Myrle Croasdale, [http://www.ama-assn.org/amednews/2006/01/30/prl20130.htm Innovative funding opens new residency slots] amednews.com, January 30, 2006. Retrieved December 5, 2008.</ref> Meanwhile, the US population continues to grow, leading to greater demand for physicians. At the same time the cost of medical services continue rising rapidly and many geographic areas face physician shortages, both trends suggesting the supply of physicians remains too low. Medicare finds itself in the odd position of having assumed control of graduate medical education, currently facing major budget constraints, and as a result, freezing funding for graduate medical education, as well as for physician reimbursement rates.<ref name=croasdale/>  This halt in funding in turn exacerbates the exact problem Medicare sought to solve in the first place: improving the availability of medical care. In response, teaching hospitals have resorted to alternative approaches to funding resident training, leading to the modest 4% total growth in residency slots from 1998-2004, despite Medicare funding having been frozen since 1996.<ref name=croasdale/>
 
  
−
===Aging of the population===
+
The debate over how to improve Medicare and resolve this problem has lasted many years without resolution. Despite, and perhaps as a result of, the [[Medicare Prescription Drug, Improvement, and Modernization Act]] enacted in 2003 and which produced the largest overhaul of Medicare in its history, Medicare continues to face serious financial problems. Because Medicare's unique role in serving the elderly population, solutions to its challenges are of vital importance to American society.
−
The fundamental problem is that the ratio of workers paying Medicare taxes to retirees drawing benefits is shrinking at the same time that the price of health care services per person is increasing.<ref>Public Agenda, [http://www.publicagenda.org/charts/fewer-workers-projected-hi-beneficiary Fewer Workers Projected Per HI Beneficiary] Public Agenda, December 4, 2008. Retrieved December 5, 2008.</ref><ref>Public Agenda, [http://www.publicagenda.org/charts/medicare-costs-person Medicare Costs Per Person], December 4, 2008. Retrieved December 5, 2008.</ref> Currently there are 3.9 workers paying taxes into Medicare for every older American receiving services. By 2030, as the baby boom generation retires, that is projected to drop to 2.4 workers for each beneficiary. Medicare spending is expected to grow by about 7 percent per year for the next 10 years.<ref name=2006report/> As a result, the financing of the program is out of actuarial balance, presenting serious challenges in both the short-term and long-term.<ref name="beyond actuarial balance 2008"/><ref name="Potetz 2008"/>
 
  
 
== Legislation and reform ==
 
== Legislation and reform ==
−
 
+
*1960&mdash;PL 86-778 [[Social Security Amendments of 1960]] (Kerr-Mill aid)
−
*1960 &mdash; PL 86-778 [[Social Security Amendments of 1960]] (Kerr-Mill aid)
+
*1965&mdash;PL 89-97 [[Social Security Amendments of 1965]], Establishing Medicare Benefits
−
*1965 &mdash; PL 89-97 [[Social Security Amendments of 1965]], Establishing Medicare Benefits
+
*1988&mdash;{{USPL|100|360}} [[Medicare Catastrophic Coverage Act of 1988]]
−
*1988 &mdash; PL 100-360 [[Medicare Catastrophic Coverage Act of 1988]]
+
*1997&mdash;{{USPL|105|33}} [[Balanced Budget Act of 1997]]
−
*1997 &mdash; PL 105-33 [[Balanced Budget Act of 1997]]
+
*2003&mdash;{{USPL|108|173}} [[Medicare Prescription Drug, Improvement, and Modernization Act]]
−
*2003 &mdash; PL 108-173 [[Medicare Prescription Drug, Improvement, and Modernization Act]]
 
−
 
 
−
In 2003 [[United States Congress|Congress]] passed the [[Medicare Prescription Drug, Improvement, and Modernization Act]], which President [[George W. Bush]] signed into law on December 8, 2003. Part of this legislation included filling gaps in prescription-drug coverage left by the Medicare Secondary Payer Act that was enacted in 1980. The 2003 bill strengthened the Workers' Compensation Medicare Set-Aside Program (WCMSA) that is monitored and administered by CMS.
 
−
 
 
−
On August 1, 2007, the U.S. House [[United States Congress]] voted to reduce payments to Medicare Advantage providers in order to pay for expanded coverage of children's health under the [[State Children's Health Insurance Program|SCHIPS]] program. As of 2008, Medicare Advantage plans cost, on average, 13 percent more per person insured than direct payment plans.<ref>Aliza Marcus, [http://www.bloomberg.com/apps/news?pid=20601070&sid=a8.4kZl7x03E&refer=home "Senate Vote on Doctor Fees Carries Risks for McCain"], ''Bloomberg News'', July 9, 2008. Retrieved December 5, 2008.</ref> Many health economists have concluded that payments to Medicare Advantage providers have been excessive. The Senate, after heavy lobbying from the insurance industry, declined to agree to the cuts in Medicare Advantage proposed by the House. President Bush subsequently vetoed the SCHIPS extension. <ref>Robert Pear, [http://www.nytimes.com/2007/08/02/health/policy/02health.html House Passes Children’s Health Plan 225-204], ''New York Times'', August 2, 2007. Retrieved December 5, 2008.</ref>
 
  
 
==Notes==
 
==Notes==
−
{{Reflist|2}}
+
<references/>
  
 
==References==
 
==References==
−
*Clark, Robert L., Richard V. Burkhauser, Marilyn Moon, Joseph F. Quinn, and Timothy M. Smeeding. ''The Economics of an Aging Society''. Wiley-Blackwell, 2004. ISBN 978-0631226161
+
*Clark, Robert L., Richard V. Burkhauser, Marilyn Moon, Joseph F. Quinn, and Timothy M. Smeeding. ''The Economics of an Aging Society''. Wiley-Blackwell, 2004. ISBN 978-0631226161.
−
*Fried, Joseph. ''Democrats and Republicans - Rhetoric and Reality''. New York: Algora Publishing, 2008.
+
*Fried, Joseph. ''Democrats and Republicans--Rhetoric and Reality: Comparing the Voters in Statistics and Anecdotes''. New York, NY: Algora Publishing, 2008. ISBN 978-0875866048.
−
*Johnson, Carrie. [http://www.highbeam.com/doc/1P2-16709948.html "Medical Fraud a Growing Problem: Medicare Pays Most Claims Without Review,"] ''The Washington Post'', June 13, 2008. Retrieved November 25, 2008.
+
*Merlis, Mark. [http://www.kff.org/medicare/upload/7744.pdf "The Value of Extra Benefits Offered by Medicare Advantage Plans in 2006."] The Kaiser Family Foundation, January 2008. Retrieved August 31, 2020.
−
*Lemieux, Jeff, Teresa Chovan, and Karen Heath. [http://content.healthaffairs.org/cgi/content/abstract/27/2/469 "Medigap Coverage And Medicare Spending: A Second Look,"] March/April 2008, Retrieved November 25, 2008.
+
*Moon, Marilyn. ''Medicare: A Policy Primer''. Urban Institute Press, 2006. ISBN 978-0877667537.
−
*Marcus, Aliza. [http://www.bloomberg.com/apps/news?pid=20601103&sid=agx1b8egpse8&refer= "Senate Vote on Doctor Fees Carries Risks for McCain,"] ''Bloomberg News'', July 9, 2008. Retrieved November 25th, 2008.
+
*Pear, Robert. "[http://www.nytimes.com/2007/08/02/health/policy/02health.html House Passes Children’s Health Plan 225-204.]" ''New York Times'' August 2, 2007. Retrieved August 31, 2020.
−
*Merlis, Mark. [http://www.kff.org/medicare/upload/7744.pdf "The Value of Extra Benefits Offered by Medicare Advantage Plans in 2006,"] The Kaiser Family Foundation, January 2008. Retrieved November 25th, 2008.
 
−
*Moon, Marilyn. ''Medicare: A Policy Primer''. Urban Institute Press, 2006. ISBN 978-0877667537
 
−
*Steuerle, C. Eugene, and Adam Carasso. [http://www.urban.org/retirement_policy/url.cfm?ID=900746-22K "The USA Today Lifetime Social Security and Medicare Benefits Calculator,"] Urban Institute, October 1, 2004. Retrieved November 25, 2008.
 
  
 
==External links==
 
==External links==
−
 
+
All links retrieved November 8, 2022.
−
*[http://cms.hhs.gov CMS official web site]
+
*[https://www.cms.gov/ CMS official web site]
−
**[http://www.cms.hhs.gov/home/medicare.asp Medicare]
+
**[https://www.cms.gov/Medicare/Medicare.html Medicare]
 
* [http://www.medicare.gov/ Medicare.gov] &mdash; the official website for people with Medicare
 
* [http://www.medicare.gov/ Medicare.gov] &mdash; the official website for people with Medicare
−
** [http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf Medicare & You 2009]
 
−
** [http://www.medicare.gov/Choices/Overview.asp Overview]
 
−
** [http://www.medicare.gov/pdphome.asp Prescription Drug Coverage]
 
 
*[http://www.mymedicare.gov/ MyMedicare.gov] &mdash; Medicare's secure online service where beneficiaries can access their own personal Medicare information
 
*[http://www.mymedicare.gov/ MyMedicare.gov] &mdash; Medicare's secure online service where beneficiaries can access their own personal Medicare information
 
* [http://www.ssa.gov/history/lbjsm.html Medicare Is Signed Into Law]
 
* [http://www.ssa.gov/history/lbjsm.html Medicare Is Signed Into Law]
 
* [http://www.ssa.gov/history/briefhistory3.html Historical Background and Development of Social Security]  
 
* [http://www.ssa.gov/history/briefhistory3.html Historical Background and Development of Social Security]  
−
* [http://www.ssa.gov/history/near65s.html Early Medicare poster]
 
 
*[http://digital.library.unt.edu/govdocs/crs/search/?q=medicare&t=fulltext&nlow=&nhi= Congressional Research Service (CRS) Reports related to Medicare] from the University of Texas Libraries
 
*[http://digital.library.unt.edu/govdocs/crs/search/?q=medicare&t=fulltext&nlow=&nhi= Congressional Research Service (CRS) Reports related to Medicare] from the University of Texas Libraries
 
*[http://www.medicareadvocacy.org Center for Medicare Advocacy] &mdash; National education & advocacy organization
 
*[http://www.medicareadvocacy.org Center for Medicare Advocacy] &mdash; National education & advocacy organization
 
*[http://www.medicare.org Medicare.org] &mdash; Medicare information site including descriptions of Part A through D
 
*[http://www.medicare.org Medicare.org] &mdash; Medicare information site including descriptions of Part A through D
−
*[http://www.agis.com/Eldercare-Basics/Legal-and-Financial/Medicare-and-Medicaid/ Medicare & Medicaid Resources]
 
 
*[http://www.kff.org/medicare Medicare] &mdash; Kaiser Family Foundation
 
*[http://www.kff.org/medicare Medicare] &mdash; Kaiser Family Foundation
 
* [http://www.allhealth.org/issues.asp?wi=7 Medicare] &mdash; Alliance for Health Reform
 
* [http://www.allhealth.org/issues.asp?wi=7 Medicare] &mdash; Alliance for Health Reform
−
* [http://www.publicagenda.org/citizen/issueguides/medicare ISSUE GUIDE: Medicare] &mdash; Public Agenda for Citizens
 
  
 
{{Credits|Medicare_(United_States)|241777359|}}
 
{{Credits|Medicare_(United_States)|241777359|}}

Latest revision as of 03:58, 9 November 2022

This article refers to Medicare, a United States health insurance program. For similarly named programs in other countries, see Medicare.
President Johnson signing the Medicare amendment. Harry Truman and his wife, Bess, are on the far right

Medicare is a federally funded health insurance program in the United States, designed to cover older individuals and those who meet other special criteria. In general, Medicare is available to U.S. citizens, or permanent legal residents having at least five consecutive years of residence in the United States, who are 65 years or older. Individuals who are under 65 and meet the citizenship or residency requirements may be eligible for Medicare if they are disabled and have received other forms of assistance such as Social Security or Social Security Disability Insurance for a minimum of 24 months.

Medicare is an entitlement program and not based on financial need. American citizens are automatically eligible for Medicare upon reaching the age of 65 because they, or their spouses, paid Social Security taxes during their working years. Medicare is very different from Medicaid, a government assistance program that provides health care benefits to certain categories of low-income individuals, although they are often associated. Unlike Medicaid, which is jointly funded by federal and state governments and has eligibility criteria which vary from state to state, Medicare is fully funded by the federal government and its criteria are consistent nationwide.

Medicare provides insurance benefits in several different areas including hospital stays, post-hospital skilled nursing care, and prescription drug coverage. There are gaps in its coverage, however, which individuals may elect to cover through private "Medigap" insurance plans, or, if they are eligible, Medicaid. Throughout its history, Medicare has experienced and continues to experience steady increases in spending due to challenges such as a growing aged population, concerns about waste and fraud, and increases in health care costs, which have led to projections of financial insolvency. For a society that values the contributions made by its population during their working life, Medicare is a significant social welfare program and efforts continue to be made to improve the program and solve its problems.

Introduction

Medicare is a social insurance program administered by the United States government providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965, by President Lyndon B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card.[1] In 1973, Medicare was expanded to cover people under the age of 65 who needed dialysis or transplants due to kidney failure, as well as those with specific disabilities.

Initially, Medicare was administered by the Social Security Administration. In 1977, it was transferred to the Department of Health and Human Services (DHHS). The Centers for Medicare and Medicaid Services (CMS), a department of DHHS, administers Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and the Clinical Laboratory Improvement Amendments (CLIA). The Social Security Administration continues to be responsible for determining Medicare eligibility and processing premium payments for the Medicare program. Since Medicare is a federal program, the rules for eligibility, coverage, and costs are constant throughout the nation.

Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9 percent (1.45 percent withheld from the worker and a matching 1.45 percent paid by the employer) of the wages, salaries, and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount on which the Medicare tax could be imposed each year. Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the entire 2.9 percent tax of self employed net earnings must be paid by the self-employed individual, however half of the tax can be deducted from the income calculated for income tax purposes.

Eligibility

In general, individuals are eligible for Medicare if they are a U.S. citizen or have been a permanent legal resident for five continuous years, and they are 65 years or older, or they are under 65, disabled and have been receiving either Social Security or the Railroad Retirement Board disability benefits for at least 24 months, or they get continuing dialysis for permanent kidney failure or need a kidney transplant, or they are eligible for Social Security Disability Insurance and have amyotrophic lateral sclerosis (ALS-Lou Gehrig's disease).

Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay any drugs that are not covered by Part D.

In 2019, Medicare provided health care coverage for over 60 million Americans. Enrollment is expected to reach 77 million by 2031, when the baby boom generation is fully enrolled.[2]

Benefits

A Medicare card, with several areas of the card obscured to protect privacy.
There are separate lines for Parts A and B, each with its own date.
There are no lines for Parts C or D, as a separate card is issued for those benefits by the private insurance company.

The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Part C or Medicare Advantage plans are another way for beneficiaries to receive their Part A, B, and D benefits.

Part A: Hospital insurance

Most individuals automatically enroll in Medicare Part A without having to pay a premium because they, or their spouse, paid sufficient taxes while working.

Medicare Part A covers hospital stays and certain services following a hospital stay. These include stays in a skilled nursing facility, such as a nursing home or hospice care for terminally ill patients, and treatment received there, such as physical therapy.

Part B: Medical insurance

Medicare Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10 percent per year) imposed for not enrolling in Part B unless actively working. There is a monthly premium charged for Part B insurance.

Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as lupron, and other outpatient medical treatments administered in a doctor's office. Medication administration is covered under Part B only if it is administered by the physician during an office visit.

Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered.

Part C: Medicare advantage plans

With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as "Medicare+Choice" or "Part C" plans. In 2000, almost 16 percent of all Medicare beneficiaries participated in "Medicare+Choice" plans.[3] This use of such plans has moved Medicare away from its original role as the insurer to a role as purchaser of health insurance.

Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the compensation and business practices changed for insurers that offer these plans, and "Medicare+Choice" plans became known as "Medicare Advantage" (MA) plans. Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MAPD.

Part D: Prescription drug plans

Medicare Part D went into effect on January 1, 2006, by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. Anyone with Part A or B is eligible for Part D. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover them, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to drugs used to treat anorexia, weight loss, or weight gain, fertility drugs, drugs to treat erectile dysfunction, drugs only for the relief of non-prescription drugs.[4]

Medicare supplement (Medigap) policies

Medicare Part A and Part B together do not cover all the medical services that individuals require. Also, there are many health insurance plans offering greater coverage that are available to younger individuals. This gap in coverage led to options for additional insurance for Medicare enrollees.

Some individuals with limited financial resources qualify for Medicaid, which covers many of the services not covered by Medicare. Others, who do not qualify for Medicaid, may elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill the gap in their needs for medical coverage. These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006, are prohibited from covering drugs.

Out-of-pocket costs

Neither Medicare Part A nor Part B pays for all of a covered person's medical costs. The program contains premiums, deductibles, and coinsurance, which the covered individual must pay out-of-pocket. Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare.

Premiums

Most Medicare enrollees do not pay a monthly Part A premium, because they (or their spouse) have had 40 or more quarters in which they paid Federal Insurance Contributions Act taxes. Only those eligible for Medicare but who do not have 40 or more quarters of Medicare-covered employment are required to pay a monthly premium.

All Medicare Part B enrollees pay an insurance premium for this coverage. Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks.

Part C and D plans may or may not charge premiums, at the programs' discretion. Part C plans may also choose to rebate a portion of the Part B premium to the member.

Deductible and coinsurance

Both Medicare Parts A and B have annual or benefit period (episode of illness) deductibles and coinsurance charges that must be paid for covered services. These are standard amounts for all individuals, although they may change from year to year.

The deductibles and coinsurance charges for Part C and D plans vary from plan to plan.

Costs and funding challenges

Medicare and Medicaid Spending as percentage of GDP.

As an expansive social insurance program, Medicare often faces funding challenges such as long-term financial viability, the aging population at large, as well as waste and fraud. According to the 2004 "Green Book" of the House Ways and Means Committee, Medicare expenditures from the American government were $256.8 billion in fiscal year 2002. Beneficiary premiums are highly subsidized, and net outlays for the program, accounting for the premiums paid by subscribers, were $230.9 billion.

These expenditures are increasing, both in absolute terms and as a percentage of the federal budget. Total Medicare spending reached $440 billion for fiscal year 2007, or 16 percent of all federal spending. The only larger categories of federal spending were Social Security and defense.

Spending on Medicare and Medicaid is projected to continue to grow with the result that the Medicare hospital insurance trust fund has been projected to become insolvent.[5][6]

While the same demographic trends that affect Social Security also affect Medicare, rapidly rising medical prices appear a more important cause of projected spending increases. The Congressional Budget Office (CBO) has indicated that:

Future growth in spending per beneficiary for Medicare and Medicaid—the federal government’s major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation’s central long-term challenge in setting federal fiscal policy. …total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population.[7]

Another segment of the cost of Medicare is attributable to fraud, which government auditors estimate costs Medicare billions of dollars a year.[8][9] The Government Accountability Office lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.[10]

Social concerns and the future of Medicare

Medicare is the largest publicly funded health insurance program in the United States and plays an essential role in caring for the needs of the elderly and disabled. For some, it represents what national health insurance could be in the United States. However, Medicare faces continuing challenges dealing with the financial viability, availability, and quality control of services that cause widespread social concerns.

When it began in the 1960s, Medicare covered approximately 19 million individuals aged over 65. By the beginning of the twenty-first century it had expanded to over 39 million, with the number projected to increase to almost 80 million by 2030.[3] As a result of the large numbers of individuals involved, its large share of the federal budget, and the rapid rate of its expansion, Medicare has been subjected to much scrutiny and changes and improvements have continually been under discussion. Competing approaches to reform include reducing per capita spending through incremental changes or major structural reforms, such as shifting Medicare to the control of private plans. Incremental approaches generally involve changing payment policies, and have been criticized as focusing on prices charged rather than the amount of use of services.[3]

As the population ages, the needs for healthcare for the elderly increase. There are many concerns about financing good quality health care that is appropriate for this segment of the population. One concern is that health insurance through Medicare will not continue, or not at an affordable price, due to federal budget cuts. Related to this is the concern that funding for Medicare provided by the Social Security Administration will be exhausted and the program become insolvent before the aging population, particularly Baby Boomers, are old enough to benefit from the taxes they pay.

The fundamental problem is that the ratio of workers paying Medicare taxes to retirees drawing benefits is shrinking at the same time that the price of health care services per person is increasing. From 3.9 workers paying taxes into Medicare for every older American receiving services as the baby boom generation retires, this figure is projected to drop to 2.4 workers for each beneficiary by 2030. However, Medicare spending is expected to grow by about 7 percent per year during that time period. As a result, the financing of the program is out of actuarial balance, presenting serious challenges in both the short-term and long-term.[6]

The debate over how to improve Medicare and resolve this problem has lasted many years without resolution. Despite, and perhaps as a result of, the Medicare Prescription Drug, Improvement, and Modernization Act enacted in 2003 and which produced the largest overhaul of Medicare in its history, Medicare continues to face serious financial problems. Because Medicare's unique role in serving the elderly population, solutions to its challenges are of vital importance to American society.

Legislation and reform

  • 1960—PL 86-778 Social Security Amendments of 1960 (Kerr-Mill aid)
  • 1965—PL 89-97 Social Security Amendments of 1965, Establishing Medicare Benefits
  • 1988—Pub.L. 100-360 Medicare Catastrophic Coverage Act of 1988
  • 1997—Pub.L. 105-33 Balanced Budget Act of 1997
  • 2003—Pub.L. 108-173 Medicare Prescription Drug, Improvement, and Modernization Act

Notes

  1. ↑ Social Security Online, Medicare Is Signed Into Law, Social Security History, Social Security Online. Retrieved August 31, 2020.
  2. ↑ Trustees Report & Trust Funds Centers for Medicare and Medicaid Services, 2008. Retrieved August 31, 2020.
  3. ↑ 3.0 3.1 3.2 Marilyn Moon, Medicare: A Policy Primer (Urban Institute Press, 2006, ISBN 978-0877667537).
  4. ↑ Drugs excluded from Part D coverage Medicare Interactive. Retrieved August 31, 2020.
  5. ↑ 2008 Annual Report of the Boards of Trustees of the Federal Hospital and Federal Supplementary Medical Insurance Trust Funds Centers for Medicare and Medicaid Services, March 25, 2008. Retrieved August 31, 2020.
  6. ↑ 6.0 6.1 Medicare’s Financial Condition: Beyond Actuarial Balance American Academy of Actuaries, March 2008. Retrieved August 31, 2020.
  7. ↑ Peter R. Orszag, The Long-Term Budget Outlook and Options for Slowing the Growth of Health Care CostsCongressional Budget Office Statement before the Committee on Finance United States Senate, June 17, 2008. Retrieved August 31, 2020.
  8. ↑ Medicare: More Effective Screening and Stronger Enrollment Standards Needed for Medical Equipment Suppliers U.S. Government Accountability Office, September 22, 2005. Retrieved August 31, 2020.
  9. ↑ Medicare Fraud and Abuse: DOJ Continues to Promote Compliance with False Claims Act Guidance, GAO Report to Congressional Committees, April 2002. Retrieved August 31, 2020.
  10. ↑ 2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds Centers for Medicare and Medicaid Services, May 1, 2006. Retrieved August 31, 2020.

References
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External links

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