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Medicare

Medicare is health insurance for people age 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD). ESRD is permanent kidney failure requiring dialysis or a kidney transplant. The different parts of Medicare help cover specific services if you meet certain conditions.

What is Covered?

Medicare payment for medical treatment is subject to annual deductibles, co-payments, and other conditions

What is not paid for by Medicare Part A and Part B:

The Original Medicare Plan does not cover everything. Health care costs not covered by Medicare will include, but are not limited to:

  • Acupuncture.
  • Deductibles, coinsurance, or copayments when you get health care services.
  • Dental care and dentures (in most cases).
  • Cosmetic surgery.
  • Custodial care (help with bathing, dressing, using the bathroom,and eating) at home or in a nursing home.
  • Health care you get while traveling outside of the United States (except in limited cases).
  • Hearing aids and hearing exams.
  • Orthopedic shoes.
  • Outpatient prescription drugs (with only a few exceptions).
  • Routine foot care (with only a few exceptions).
  • Routine eye care and most eyeglasses (see exception above for one pair of standard frames after cataract surgery with an introcular lens).
  • Routine or yearly physical exams.
  • Certain screening tests
  • Certain shots (vaccinations)
Eligibility

Sixty-five or older and have worked enough in jobs covered by social security to qualify. ("fully insured" for Social Security Retirement Benefits)

or

Disabled and receiving Social Security Disability Insurance Benefits for 24 months

Income Eligibility

None

Asset Eligibility

None

Apply at

Social Security --- Visit www.medicare.gov for information on how to enroll for Medicare  and other questions.

Appeals
  • You can appeal any denial, termination, or reduction of benefits
  • You must file an appeal within 60 days of the date of the written notice you disagree with
  • Reconsideration - Generally, you probably do NOT need a lawyer at this stage.  You can file this appeal yourself, or you may be able to get help from the Senior Health Insurance Assistance Program.
  • Hearing before an Social Security Administrative Law Judge. The chances of a successful appeal are much better at this stage if you are represented by a lawyer.  This is the only opportunity to testify and to have other witnesses testify.  Generally, all of your evidence, paper records or testimony of witnesses should be submitted by this stage.
  • Social Security Appeals Council This appeal is a review of the file.  There is no hearing at this stage.
  • U.S. District Court  The court makes a very limited review of the case.  It looks only at whether there are "errors of law" and whether the decision is reasonable ("supported by substantial evidence").

Medicare appeals can be complicated. You should consider getting legal help if you have a problem with Medicare coverage or payment decisions.

Source of Funds

Medicare Trust Fund

Other Programs
Medicare Part C: Medicare Advantage Maryland Medicaid Pharmacy Program (MMP) Medicare - Part D (Drug Coverage)
Sources of Law

Federal Law:  42 U.S.C. § 1395 to 1395gg The Medicare law is also referred to as Title XVIII of the Social Security Act.

Federal Regulations:  The core Medicare regulations are at  42 C.F.R. Parts 400 to 424 and 460-498

Federal Policy Materials: The Department of Health and Human Services (through the Centers for Medicare and Medicaid Services - CMS) publishes informal guidelines that are widely used and often binding on intermediaries and carriers at the first level of decision-making. When you appeal your case, you should know that the guidelines are "advisory only". Administrative law judges or the Appeals Council are not required to follow these guidelines.

Originally posted by Anonymous on Aug 17, 2010, last updated by Anonymous on Oct 24, 2012
Tags: Government Benefits & Services > Medical Benefits, Health > Medicaid/Medicare, Senior Citizens

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