Medicare (United States)
- This article refers to Medicare, a United States health insurance program. For similarly named programs in other countries, see Medicare.
Medicare is a health insurance program administered by the United States government, covering people who are either age 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.
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 Departments of Labor and 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.
Since the beginning of the Medicare program, CMS has contracted to private companies to assist with administrating the program. These contractors are commonly already in the insurance or health care area. Contracted process include claims and payment processing, call center services, clinician enrollment, and fraud investigation.
Taxes imposed to finance Medicare
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% (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 tax is 2.9% of net earnings from self-employment, and the entire amount is paid by the self-employed individual.
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.
In general, individuals are eligible for Medicare if they (or their spouse) worked for at least 10 years in Medicare-covered employment and are at least 65 years old and are a citizen or permanent resident of the United States of America.
Individuals who are under 65 years old can also be eligible if they are disabled or have end stage renal disease. People under 65 and disabled must be receiving disability benefits from either Social Security or the Railroad Retirement Board for at least 24 months before Medicare automatic enrollment occurs.
Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states those with 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.
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. Medicare Advantage plans are another way for beneficiaries to receive their Part A, B and D benefits.
Part A: Hospital Insurance
Part A covers hospital stays (including stays in a skilled nursing facility) if certain criteria are met:
- The hospital stay must be at least three days, three midnights, not counting the discharge date.
- The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. For instance, hospital stay for broken hip and then nursing home stay for physical therapy would be covered.
- 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.
- 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.
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 2007, $124.00 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell.
If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period.
Part B: Medical Insurance
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% per year) imposed for not taking Part B if not actively working.
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.
As with all Medicare benefits, Part B coverage is subject to medical necessity. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003.
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. 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. In addition to offering comparable coverage to Part A and Part B, Medicare Advantage plans may also offer Part D coverage.
Part D: Prescription Drug plans
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 benzodiazepines, cough suppressant and barbiturates. 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.
It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid will pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Neither Part A nor Part B pays for all of a covered person's medical costs. The program contains premiums, deductibles and co-pays, 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.
Some people elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill 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. There is currently no CMS approved supplemental coverage available to fill the Donut Hole, a coverage gap built into Medicare's Part D benefit.
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:
- $226.00 per month (2007) for those with 30-39 quarters of Medicare-covered employment, or
- $410.00 per month (in 2007) for those with less than 30 quarters of Medicare-covered employment and who are not otherwise eligible for premium-free Part A coverage.
All Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2007 is $93.50 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 $105.80, $124.40, $142.90, or $161.40 for 2007, with the highest premium paid by individuals earning more than $200,000, or married couples earning more than $400,000.
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.
Deductible and coinsurance
Part A — For each benefit period, a beneficiary will pay:
- A Part A deductible of $992 (in 2007) for a hospital stay of 1-60 days.
- A $248 per day co-pay (in 2007) for days 61-90 of a hospital stay.
- A $496 per day co-pay (in 2007) for days 91-150 of a hospital stay, as part of their limited Lifetime Reserve Days.
- All costs for each day beyond 150 days
- Coinsurance for a Skilled Nursing Facility is $124.00 per day (in 2007) for days 21 through 100 for each benefit period.
- A blood deductible of the first 3 pints of blood needed in a calendar year, unless replaced.
Part B — After a beneficiary meets the yearly deductible of $131.00 (in 2007), 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-particpiating Medicare providers.
The deductibles and coinsurance charges for Part C and D plans vary from plan to plan.
Payment for services
Medicare contracts with regional insurance companies who process over one billion fee-for-service claims per year. In 2003, Medicare accounted for almost 13% of the entire Federal Budget. Based on the CMS projections, 33 cents of every dollar spent on health care in the U.S. is paid by Medicare and Medicaid (including State funding). Looked at from three different perspectives, 61 cents of every dollar spent on nursing homes, 47 cents of every dollar received by U.S. hospitals, and 27 cents of every dollar spent on physician services is funded by Medicare or Medicaid.
Reimbursement for Part A services
For institutional care such as hospital and nursing home care, Medicare uses prospective payment systems. A prospective payment system is one in which the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care used. The actual allotment of funds is based on a list of diagnosis-related groups (DRG). The actual amount depends on the kind of diagnosis made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "upcoding," when a physician makes a more severe diagnosis to hedge against accidental costs.
Reimbursement for Part B services
Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991, the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.
The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. Firstly, it introduced the Medicare Fee Schedule, which took effect in 1992. Secondly, it limited the amount Medicare non-providers could balance bill Medicare beneficiaries. Thirdly, it introduced the Medicare Volume Performance Standards (MVPS) as a way to control costs.
On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS). The MFS assigned Relative Value Units (RVUs) for each procedure from the Resource-Based Relative Value Scale (RBRVS). The Medicare reimbursement for a physician was the product of the RVU for the procedure, a Geographic Adjustment Factor (GAF) for geographic variations in payments, and a global Conversion Factor (CF) which converts RBRVS units to dollars.
From 1992 to 1997, adjustments to physician payments were adjusted using the MEI and the MVPS, which essentially tried to compensate for the increasing volume of services provided by physicians by decreasing their reimbursement per service.
In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR). This was done because of highly variable payment rates under the MVPS. The SGR attempts to control spending by setting yearly and cumulative spending targets. If actual spending for a given year exceeds the spending target for that year, reimbursement rates are adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVUs.
Since 2002, actual Medicare Part B expenditures have exceeded projections.
In 2002, payment rates were cut by 4.8%. In 2003, payment rates were scheduled to be reduced by 4.4%. However, Congress boosted the cumulative SGR target in the Consolidated Appropriation Resolution of 2003 (P.L. 108-7), allowing payments for physician services to rise 1.6%. In 2004 and 2005, payment rates were again scheduled to be reduced. The Medicare Modernization Act (P.L. 108-173) increased payments 1.5% for those two years.
In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109-362), and held physician payments in 2006 at their 2005 levels. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.
MFS has been criticized for not paying doctors enough because of the low conversion factor. By adjustments to the MFS conversion factor, it is possible to pay all doctors more or less depending on how much money the person paying (CMS in this case) is willing to pay.
Office medication reimbursement
Chemotherapy and other medications dispensed in a physician's office are reimbursed according to the Average Sales Price, a number computed by taking the total dollar sales of a drug as the numerator and the number of units sold nationwide as the denominator. The current reimbursement formula is known as "ASP+6" since it reimburses physicians at 106% of the ASP of drugs. Pharmaceutical company discounts and rebates are included in the calculation of ASP, and tend to reduce it. ASP+6 superseded Average Wholesale Price in 2005, after a 2004 front-page New York Times article drew attention to the inaccuracies of Average Wholesale Price calculations. Average Wholesale Price (AWP) reimbursement tended to be more favorable for physicians, since it was an arbitrary number provided by the pharmaceutical company to CMS. Since the change, some outpatient chemotherapy drugs are "underwater," since the wholesale price from drug distributors may be higher than ASP+6 for some drugs. Stakeholders are involved in active discussions with the United States Congress to address this issue.
Medicare faces continuing financial issues. 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 just last year.
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. 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.
Part of the cost of Medicare is fraud, which government auditors estimate costs Medicare billions of dollars a year. 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.
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. Surveys suggest that there’s no public consensus behind any specific strategy to keep the program solvent.
A 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%.
Legislation and reform
- 1960 — PL 86-778 Social Security Amendments (Kerr-Mill aid)
- 1965 — PL 89-97 Medicare
- 1988 — PL 100-360 Medicare Catastrophic Coverage Act
- 1997 — PL 105-33 Balanced Budget Act of 1997
- 2003 — PL 108-173 Medicare Prescription Drug, Improvement, and Modernization Act
In 2003 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 Democrats pushed through legislation in the United States Congress making deep cuts in federal payments to Medicare health maintenance organizations, defying a veto threat from President Bush. 
- Administration on Aging
- Long-term care
- Medicare (Australia)
- Medicare (Canada)
- Medicare dual eligible
- National Health Service (United Kingdom)
- Quality improvement organizations
- Railroad Retirement Board
- Stark Law
- http://www.uihealthcare.com/topics/aging/agin3390.html Medicare: Part A & B
- Lauren A. McCormick, Russel T. Burge. Diffusion of Medicare's RBRVS and related physician payment policies - resource-based relative value scale - Medicare Payment Systems: Moving Toward the Future Health Care Financing Review. Winter, 1994.
- Medicare's Physician Payment Rates and the Sustainable Growth Rate.(PDF) CBO TESTIMONY Statement of Donald B. Marron, Acting Director. July 25, 2006.
- "2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplimentary Medical Insurance Trust Funds, 1 May 2006 (PDF)" (PDF). Unknown parameter
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- ""High-Risk Series: An Update" U.S. Government Accountability Office, January 2003 (PDF)" (PDF). Unknown parameter
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- http://www.cms.hhs.gov/OfficeofLegislation/COI/list.asp CMS Website, accessed 2/15/07
- CMS official web site at cms.hhs.gov
- Medicare at cms.hhs.gov
- Medicare.gov — the official website for people with Medicare
- Official Medicare publications at Medicare.gov — includes official publications about current Medicare benefits
- Medicare & You handbook for 2007 at Medicare.gov — includes information about current Medicare benefits
- Information about the 1-800-MEDICARE helpline from Medicare.gov — a 24X7 toll-free number to call with questions about Medicare
- Medicare Modernization Act at Medicare.gov
- Medicare Plan Choices at Medicare.gov — basic information about plan choices for Medicare beneficiaries, including MA Plans
- Prescription Drug Coverage homepage at Medicare.gov — a central location for Medicare's web-based information about the Part D benefit
- Landscape of plans — state-by-state breakdown of all plans available in an area, both stand-alone PDPs, as well as MA-PD plans
- Official Medicare publications at Medicare.gov — includes official publications about current Medicare benefits
- MyMedicare.gov — Medicare's secure online service where beneficiaries can access their own personal Medicare information
- Medicare Is Signed Into Law page from ssa.gov — material about the bill-signing ceremony
- Historical Background and Development of Social Security from ssa.gov — includes information about Medicare
- Detailed Chronology of SSA from ssa.gov — includes information about Medicare
- Early Medicare poster from ssa.gov
- Congressional Research Service (CRS) Reports related to Medicare from the University of Texas Libraries
- Center for Medicare Advocacy — National education & advocacy organization.
- Medicare Rights Center — Education and advocacy organization.
- Medicare.org — Medicare information site including descriptions of Part A through D
- Kaiser Family Foundation — Wide range of free information, including a drug benefit calculator, about the Medicare program and other U.S. health issues.
- State Health Facts — Data on health care spending and utilization, including Medicare; provided by the Kaiser Family Foundation.
- Medicare - Alliance for Health Reform The nonpartisan, nonprofit Alliance for Health Reform offers information about health reform, in a number of formats, to elected officials and their staffs, journalists, policy analysts and advocates.
- HealthDecisions.org — Medicare information from America’s Health Insurance Plans (a national association of American health insurers).
- Social Security and Disability News Resource Center
- Issue Guide on Medicare — Policy alternatives and public opinion analysis on Medicare from Public Agenda Online
- How Stuff Works - Medicare