Medicare and Medicaid

You may be eligible for these government health care insurance programs:


The federal Medicare program is a health insurance program for the elderly and disabled. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS), which was formerly the Health Care Financing Administration (HCFA).

Medicare provides benefits for:

  • Those who have reached age 65 and are entitled to receive Social Security or Railroad Retirement benefits
  • Disabled individuals of any age who have received Social Security or Railroad disability benefits for at least two years

Other Medicare participants may include:

  • Persons eligible for Social Security benefits who have end-stage renal disease and require kidney dialysis treatment
  • Persons over age 65 who are not eligible for either Social Security or Railroad Retirement benefits who purchase monthly Medicare coverage

Medicare Part A Hospital Insurance Program

This program provides beneficiaries with coverage for mostly hospital-related claims, including:

  • Inpatient hospital care
  • Limited post-hospital skilled nursing facility
  • Home health care
  • Hospice care

Medicare Part B Supplementary Insurance Program

This program focuses on medical costs other than hospitalization, such as:

  • Physician and surgical services
  • Diagnostic tests
  • Home health care
  • Physical, speech and occupational therapy
  • Medical supplies
  • Durable medical equipment
  • Ambulance services
  • Some preventive care services

Enrollment in Part B coverage is optional.

Each program requires different deductible and co-payment amounts.

Medicare Exclusions

Medicare Part A and Part B coverage doesn't include:

  • Custodial nursing home care
  • Most outpatient prescription drugs
  • Routine physical examinations
  • Routine eye examinations and eyeglasses
  • Hearing examinations and hearing aids
  • Routine dental services
  • Routine foot care and orthopedic shoes
  • Most immunizations
  • Personal convenience items
  • Cosmetic surgery

Medicare Part C

Any individual who is entitled to Medicare benefits under Part A and enrolled under Part B may choose from several types of health insurance plans under Medicare Part C (Medicare Choice program) including:

  • Coordinated Care Plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs)
  • Private Fee-for-Service Plans
  • Medical Savings Accounts (MSAs)

Medicare Part D

Medicare Part D is an optional prescription drug benefit. People who are entitled to benefits under Part A or enrolled in Part B are eligible for Part D. They can enroll in a stand-alone drug plan or private health plan that offers drug coverage. Participants pay a deductible, coinsurance and a monthly premium.

Medigap Plans

Medicare supplemental insurance (Medigap) plans provide coverage for:

  • Medicare deductible and co-payment amounts
  • Some health services not covered by Medicare

The federal Qualified Medicare Beneficiary program (QMB) and the Selected Low-Income Medicare Beneficiaries program (SLMB) may provide payment for Medicare deductibles and co-payments to qualified individuals.

Medicare Administration and Appeals

The Medicare program is administered directly by:

  • Peer review organizations (PROs) for Part A hospital claims
  • Insurance companies, called ''fiscal intermediaries,'' for other Part A claims
  • ''Carriers'' are companies┬ácontracted with the Department of Health and Human Service, for Part B

The particulars of program administration for Medicare Part C are still being developed.

The first decision regarding Medicare coverage is made by the provider of the medical service. This decision is followed by an ''initial determination'' from the PRO, intermediary or carrier. It is this initial determination which triggers the appeals process for both Parts A and B; thus a patient must be certain that the health provider submits a Medicare claim to the PRO, intermediary or carrier. This initial determination will also trigger the appeal process for the new Medicare Part C Program.

Basically, Part A appeals parallel the process for all other Social Security claims, beginning with a "Reconsideration," and proceeding from there to an administrative law judge hearing (for PRO/hospital claims over $200 and for other claims over $100), to the Social Security Appeals Council, and finally to federal court (for PRO/hospital claims over $2,000 and for other claims over $1,000).

Part B denials are subject first to a Review by the carrier and then to a hearing before a hearing officer employed by the carrier. Denials are appealable to an administrative law judge after the carrier hearing if the amount in controversy is still $500 or more; judicial review is available if the amount in controversy is $1,000 or more. Amounts for similar claims can be combined.


Medicaid is a jointly-financed federal-state health care program that provides medical assistance to:

  • Low-income elderly
  • The blind or disabled
  • Families with dependent children

Medicaid is the primary public financing program for long-term nursing home and home care services.

Eligibility requirements vary greatly from state to state.

All states, however, must provide Medicaid coverage to the categorically eligible. Categorical eligibility is related to economic need and income.

States may also provide Medicaid coverage to the medically needy, frequently persons in need of expensive nursing home or hospital care.

Generally, Medicaid pays for:

  • Inpatient and outpatient hospital services
  • Prescription drugs
  • Physician services
  • Laboratory and X-ray services
  • Custodial nursing home care

Benefits vary from state to state, and may also cover:

  • Dental care
  • Medical equipment
  • Foot care
  • Optometry services
  • Clinic services
  • Rehabilitative services
  • Transportation to obtain medical care

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a federal health benefit program for eligible retired armed forces personnel and family members. The CHAMPUS program is supervised by the National Tri-Care Support Office, which provides a handbook describing program rules and benefits.

Questions for Your Attorney

  • Should I sign up for Medicare Parts A, B, C, and D?
  • What does a Medigap insurance plan cover?
  • Who is eligible for Medicaid?
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