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U.S. Medicare Health Insurance Information

Disabled World: Revised/Updated: 2015/03/16

Synopsis: The U.S. Medicare system was established in 1965 under the Social Security Act and is available to people who fall into three categories.

Main Document

Medicare was established in 1965, authorized under Title XVIII of the Social Security Act and is available to people who fall into three categories. Most people become eligible for Medicare by virtue of attaining age sixty-five. Medicare is a health insurance program for persons age sixty-five or older, persons under the age of sixty-five years with certain disabilities, as well as people of any age with End-Stage Renal Disease. Medicare has three kinds of insurance within the program. Part A involves Hospital Insurance, Part B involves Medical Insurance, and Part D provides a level of Prescription Drug Coverage. Medicare is associated with the U.S. Social Security Administration.

Health care - (healthcare) is defined as the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings. Health care is delivered by practitioners in allied health, dentistry, midwifery (obstetrics), medicine, nursing, optometry, pharmacy, psychology and other health professions. It refers to the work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Primary care - Refers to the work of health professionals who act as a first point of consultation for all patients within the health care system.

Secondary care - The health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists.

Tertiary care - Specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.

Quaternary care - The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed.

Home and community care - Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance and distribution of needle-exchange programs for the prevention of transmissible diseases.

Part A Hospital Insurance: The majority of people do not pay a premium for Part A Hospital Insurance because either the person themselves or a spouse has already paid for the coverage through their payroll taxes while working. Medicare Part A Insurance assists in covering inpatient hospital care, to include critical access hospitals, and skilled nursing facilities; although it does not cover either custodial or long-term care. Medicare Part A Insurance assists in covering hospice care, as well as some home health care. Persons with Medicare Part A Insurance must meet specific conditions in order to receive these benefits.

Part A covers:

  • Inpatient hospital services up to 90 days per "spell of illness"
  • Skilled nursing facility services for up to 100 days per spell of illness following a 3+ day hospital stay
  • Home health care up to 100 visits per spell of illness following a 3+ day hospital stay
  • Hospice care
  • Inpatient psychiatric care, for up to 190 days during a beneficiary's lifetime
  • Blood (after the beneficiary pays for the first 3 pints per year)

Part A: For each "spell of illness," beneficiaries have a $912 deductible for an inpatient hospital stay of 1-60 days and daily coinsurance starting the 61st day. If they use a skilled nursing facility for more than 20 days in a spell of illness, they must pay $114 per day for days.

Part B Medical Insurance: The majority of people do pay a monthly premium for Part B Medical Insurance. Medicare Part B Insurance assists with coverage of doctors' services, outpatient care, as well as some additional medical services that Medicare Part A Insurance does not cover; for example, some of the services of physical and occupational therapists, or some home health care services. Medicare Part B assists in paying for covered services and supplies when they are deemed medically necessary.

Part B covers:

  • Physicians' services, including office visits and a one-time physical examination for new beneficiaries
  • Durable medical equipment (e.g., wheelchairs, oxygen) and supplies
  • Outpatient hospital services
  • Outpatient mental health services
  • Clinical laboratory (e.g., blood tests, some screening tests, etc.) and diagnostic tests
  • Outpatient occupational, physical, and speech therapy
  • Home health care not preceded by a hospital stay and visits over the 100-day Part A limit
  • Some preventive services (e.g., mammograms, diabetes screening)
  • Blood (after the beneficiary pays for the first 3 pints per year)

Part B: Beneficiaries have an annual deductible of $110. In addition, most Part B services require coinsurance of 20 percent of the Medicare-approved amount.

Medicare Part D Prescription Drug Coverage:The majority of people will pay a monthly premium for Medicare Part D Coverage. Beginning on January 1, 2006, Medicare Part D Coverage became available to everyone with Medicare coverage in order to assist with prescription drug costs. Private companies provide the insurance; beneficiaries are able to choose among drug plans and pay a monthly premium. As with other forms of insurance, of a person decides not to enroll in a plan when they are first eligible, they may pay a penalty should they decide to join at a later time.

In 2003, Medicare provided coverage to:

  • 35 million persons age 65 and older - At age 65, individuals qualify for Medicare if they or their spouses paid Social Security taxes for at least 40 calendar quarters (10 years) or if they qualify for Railroad Retirement benefits.
  • 6 million persons under age 65 with disabilities Those under age 65 who have received Social Security Disability Insurance (SSDI) cash benefits for at least 24 months are eligible for Medicare.
  • Almost 100,000 persons under age 65 with end-stage renal disease (ESRD) Those with ESRD under age 65 are eligible for Medicare if they or their spouses paid Social Security taxes for at least 40 quarters.
  • In 2003, Medicare spent slightly more than $280 Billion on both benefits and administrative costs.
  • Approximately forty-five percent of Medicare expenses in 2003 were related to payments for inpatient or outpatient hospital services.
  • An additional seventeen-percent of costs were for physician fee schedule services.
  • Payment to private Medicare plans accounted for thirteen percent, post-acute care such as home health and skilled nursing facility care, accounted for an additional nine-percent of Medicare's expenses.
  • Additional benefits and administrative costs made up fourteen and two-percent, respectively.



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