Medicare

Medicare is a federal health insurance program launched in 1965 to provide health insurance assistance to individuals age 65 or older and those with certain disabilities or diseases. Eligibility is available to individuals no matter what their level of income may be. It does not depend upon financial need, differing from Medicaid in that respect. Medicare is financed largely by FICA withholding taxes from wages.

Medicare Benefits and Programs

Medicare offers a set of benefits that are quite comprehensive. It also provides multiple service delivery options. Medicare recipients can elect to receive services from “Traditional Medicare” or “Original Medicare”, which is Medicare Parts A and B, or from a number of private “Medicare Advantage” plans.

No matter what beneficiaries choose, they retain coverage for Part A benefits including home health, inpatient hospital, and hospice care. Additionally, they have Medicare Part B benefits, including outpatient hospital, physician, ambulance, home health, and medical equipment and supplies.

Services and Exceptions

Health care services are provided by Medicare only when meeting its definition of medical necessity. Generally, a service is required to be needed for diagnosing or treating an illness or injury for it to be qualified as a Medicare benefit. However, some health care screening was added by Congress to Medicare benefits in 1990.

In spite of their necessity, certain services are excluded by Medicare as part of its benefits. The exceptions include:

1. Custodial care such as most longer term nursing home care

2. Most care given outside the borders of the United States

3. Hearing aids

4. Routine eye care

5. Routine dental care

6. Routine foot care

7. Eyeglasses unless needed with cataract surgery

8. Dentures

9. Routine physical exams with the exception of initial exams for new beneficiaries

10. Cosmetic surgery

11. Acupuncture and homeopathic treatments

Who Runs Medicare?

The Centers for Medicare & Medicaid Services (CMS)
Once called HCFA, CMS is the government agency tasked with administering Medicare and Medicaid. The headquarters are located in Baltimore with 10 regional offices throughout the country. CMS is the biggest agency of the Department of Health & Human Services.

The Social Security Administration (SSA)

The SSA oversees eligibility for Medicare and Social Security recipient enrollments. It also processes Medicare’s low income subsidy program.

The Office of Medicare Hearings and Appeals (OMHA)

Operating under the Department of Health and Human Services (HHS), OMHA provides hearings as part of the Medicare appeals process.