Medicare: The Basics

Today with most Americans living healthier lives and medical knowledge multiplying at an astounding rate, the percentage of our population consisting of older persons is rising steadily. One study found that the number of people over 64 will more than double by the year 2030. And between 1980 and 2030, the population over the age of 84 will triple. Overall, the elderly will represent 19 [ercent of the population in 2030 as compared with around 11 to 12 percent today.
By the time the new Medicare program was introduced in 1965, America was clamoring for a federally-supported system of health insurance for senior citizens. It has always been inevitable that healthcare expenditures tend to be greater for those in their mid 60's and above. Up untill 1965, older people had been largely at the mercy of these costs during a time in their lives when tey could ill afford to pay for them. Medicare represents the U.S. government's solution to this problem.
History
The medicare program became law July 31, 1965 under Title XVIII of the Social Security Act. Medicare is a government-regulated health insurance program for senior citizens and certain other disabled persons which is administered through the Health Care Financing Administration (HCFA). This body is responsible for certifying providers of medical care to perform services under Medicare. The bill which established Medicare actually brought about a three-part plan of benefits: Medicare Part A (a general Hospital Insurance plan), Medicare Part B (a supplementary Medical Insurance plan), and Medicaid (a separate comprehensive healthcare package for poor families).
Part A: Part A is the basic hospital coverage Medicare plan, available automatically to those 65 years of age or older. Persons having received social security benefits for at least 24 months or receiving Railroad Retirement benefits are also eligilbe. Benefits provided under Part A are:
*An unlimited number of days of inpatient hospital care (for services approved under Medicare). There is a deductible for the first contnuous period of hospitalization during the calendar year.
*Up to 150 days of care in a skilled nursing facility with co-insurance for the first eight days.
*An unlimited number of home health service visits, including 20% co-insurance for certain durable medical equipment.
*Hospice care for terminally ill patients.
Part B: Medicare Part B is a Supplementary Medical Insurance plan offered on an optional basis to all those who qualified for Part A. It is also available to persons who have been receiving Social Security or Railroad Retirement benefits for at least 24 months. Part B is financed through a monthly premium paid by each participant. For those collecting Social Security, this premium amout is deducted from their monthly Social Security check. The U.S. government adds three times this amount for the fund for Part B. The annual deductible for Part B is $75, and Medicare pay 80% of the expenses above this amount for approved medial procedures. These are:
*Physician or surgeon services - any location
*Home healthcare visits (if not covered by hospital insurance)
*Diagnostic testing (x-ray, laboratory, etc.)
*Physical therapy and speech pathology (outpatient)
*X-ray, radium, radioactive isotope therapy
*Surgical dressings, durable medical equipment rental
*Ambulance transportation
*Blood clotting factors and equipment for their self-administration
*Supplies and services provided by hospital or physician to outpatients
*Surgery on jaw or facial bones performed by dentist (also dental procedures which require hospital stay)
*Outpatient rehabilitation services and facilities (qualified professionals and facilities)
*Antigens prepared and administered by different doctors
*Pneumoccal vaccine (no cost-sharing)
*Hepatitis B vaccine (for high or intermediate risk patients in hospital or renal dialysis facility)
*Certified nurse or midwife services
*Partial hospitalization services
*Mammography screening
*In-home respite care for chronically dependant persons (80 hour/year maximum)
*Intravenous drugs for home usage (supplies, equipment, nursing, and pharmacy services)
Procedures and supplies covered by medicare must be sold and/or administered by an approved Medicare doctor or supplier. These organizations have ll signed apreements to participate in the program and must be certified by the Health Care Financing Administration. the opportunity to sign this apreement comes on an annual basis. All doctors and suppliers are listed in the Medicare-Participating Physician/Supplier Directory, which is available for review at local Social Security offices and for purhcase from any Medicare carrier.
All supplies and services provided by these organizations must meet strict standards for quality, necessity, and proper medical setting. Whether or not these criteria are satisfied is determined by local Peer Review Organizations or PRO's. These are groups of practicing physicians paid by the federal government to review and insure quality of those services paid for by Medicare. Their decisions, however, are not always final. Patients can appeal the conclusions of PRO boards if they disagree. Then the disputed amount is $200 or more, a hearing by an Administrative Law Judge may be requested; $2,000 or more may warrant a federal court hearing.
Medicare as A Second Payor
Medicare laws are fairly explicit in their description of when Medicare payment will be secondary to another in-force plan. Almost any employee health coverage will be the primary plan unless otherwise specified by the employee. Even when an employee plan states that it will pay expenses only after Medicare, federal law stipulates that Medicare is the secondary benefit. Employees can elect to make Medicare their primary coverage, but federal law prohibits an employer from having an insurance plan which specifically encourages them to do this.
Possibly the largest complaint about Medicare at this point is its lack of coverage for long-term custodial care. Medicare will not pay expenses for nursing homes which provide personal maintenance services (hygiene, eating, dressing, etc.) rather than certified nursing care, Unfortunately, custodial care presents a greater financial risk for many senior citizens than does actual nursing home benefits, and some employers include this as an option in their plans.
Regardless of its shortcomings, however, Medicare has proven to be a program which thoudands of older Americans depend on every day. It gives them a firm foundation on which to base post-retirement medical benefits. Medicare represents an important step toward the medical security that seniors so desperately need.

(Thanks to VASA BROUGHER for the above information.)