127.Hospital and Medical Insurance Benefits Provided

127.1What is Medicare?

The Health Insurance Program, commonly known as “Medicare”, provides comprehensive health insurance protection to the aged, disabled, and those with end-stage kidney disease.

127.2What are the parts of the Medicare program?

There are four parts to the Medicare program. (See Chapter 24.) Medicare hospital insurance (Part A) helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care. Medicare medical insurance (Part B) helps pay for physician services, outpatient hospital services, outpatient physical therapy, other medical services, and supplies and equipment that are not covered by Part A. Medicare Advantage Plans (Part C) are plans offered by private companies that contract with Medicare to provide all Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. Some plans also offer prescription drug coverage. The Medicare Prescription Drug Benefit (Part D) provides outpatient prescription drug coverage for the aged and disabled.

127.3Who administers the Medicare program?

The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program. It sets the standards for hospitals, skilled nursing facilities, home health agencies, hospices, and other providers and suppliers of services in order to receive payment for Medicare-covered services and items. CMS sets the standards used by Utilization and Quality Peer Review Organizations, intermediaries, and carriers in making payment and coverage decisions for health care furnished to individuals who have hospital or medical insurance.

127.4What role does SSA have in the Medicare program?

We provide beneficiary services for the Medicare program. Social Security offices accept and process applications for enrollment in Part A and B. Social Security also responds to beneficiary and public inquiries. We also perform some data processing support and premium billing and collection activities.

127.5How are Medicare premiums paid?

Medicare Part B premiums must be deducted from Social Security benefits if the monthly benefit covers the deduction. If the monthly benefit does not cover the full deduction, the beneficiary is billed. Beneficiaries may elect deduction of Medicare Part C (Medicare Advantage) from their Social Security benefit. Some Medicare Advantage plans include a reduction in the Part B premium. Social Security takes that reduction into account, as soon as we are notified of the reduction by CMS. Beneficiaries may also elect deduction of their prescription drug plan premium from their Social Security benefit.

For more information about Medicare premiums, go to Medicare & You 2011 at: www.medicare.gov/publications/pubs/pdf/10050.pdf