Medicare_Supplementary Medical Insurance

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Program Accomplishments

In fiscal year 2007, 40,764,000 persons were enrolled for supplementary medical insurance. In fiscal year 2008, the number of enrollees is estimated to be 41,225,000. In fiscal year 2009, the number of enrollees is estimated to be 41,993,000.

Uses and Use Restrictions

Managed care benefits are paid on the basis of Medicare capitation rates.

Fee-for-service benefits are paid on the basis of fee schedules or other approved amounts for services furnished by physicians and other suppliers of medical services to aged or disabled enrollees.

Benefits are paid on the basis of prospective payment systems for covered services furnished by participating providers such as hospitals, skilled nursing facilities and home health agencies.

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Eligibility Requirements

Applicant Eligibility

All persons who are eligible for premium-free hospital insurance benefits (see 93.773), and persons age 65 and older who reside in the United States and are either citizens or aliens lawfully admitted for permanent residence who have resided in the United States continuously during the five years immediately preceding the month in which the application for enrollment is filed, may voluntarily enroll for Part B supplementary medical insurance (SMI).

The beneficiary pays a monthly premium and an annual deductible.

Beginning in calendar year 2008, the Part B premiums have been set based upon beneficiary income.

The calendar year 2008 premiums range from $96.40 to $238.40 per month.

The annual deductible is $135.00.

Some States and other third parties may pay the SMI PART B premium on behalf of qualifying individuals.

Beneficiary Eligibility

Persons age 65 and over, and persons under age 65 who qualify for hospital insurance benefits.

Credentials/Documentation

Proof of age, disability or lawful admission status. This program is excluded from coverage under OMB Circular No. A-87.

Aplication and Award Process

Preapplication Coordination

None.

This program is excluded from coverage under E.O.

12372.

Application Procedures

Telephone or visit the local Social Security Office. Most persons entitled to hospital insurance and already receiving benefits from Social Security or the Railroad Retirement Board are enrolled automatically for supplementary medical insurance. Since the program is voluntary, you may decline coverage. Persons not entitled to hospital insurance must file an application. This program is excluded from coverage under OMB Circular Nos. A-102 and A-110.

Award Procedures

After review of the application is completed, the applicant will be notified by mail.

Deadlines

Certain individuals may enroll during a special enrollment period (SEP) if they are covered under a group health plan (GHP) when first eligible to get Medicare: (1) individuals age 65 or older who are covered under a GHP based on their own or a spouse's current employment; and (2) disabled individuals under age 65 who are covered under a GHP based on their own or any family member's current employment. If the coverage of disabled individuals under age 65 was not through a large group health plan (LGHP), that is, a plan that covers employees of at least one employer that normally employs at least 100 employees, no family member other than a spouse qualifies for a special enrollment period. An SEP enrollment may occur during any month the individual is covered under the GHP based on current employment or, during the eight month period that begins the first month after employment or GHP coverage ends, whichever occurs first. Months of coverage under the GHP based on current employment are excluded from the calculation of the premium surcharge. Individuals may also enroll during the General Enrollment Period (FGEP) that takes place January through March of each year. SMI Part B coverage begins July 1 of the year individuals enroll. There is a 10 percent premium surcharge for each full 12-month period a person could have been enrolled but was not in SMI Part B.

Authorization

Social Security Act Amendments of 1965, Title XVIII, Part B, Public Law 89-97, as amended; Public Laws 90-248, 92-603, 93-233, 94-182, 95-210 and 95-292, 42 U.S.C. 1395 et seq.; Social Security Disability Amendments of 1980, Public Laws 96-265 and 97-248; Section 1, Public Law 98-21; Subtitle A, Public Law 98-369, as amended; Public Laws 98-460, 99-272, 99-509, and 100-203, 42 U.S.C. 1305 Note; Medicare Catastrophic Coverage Repeal Act of 1988, Title I, Subtitle B, Title II, Subtitles A and B, Title IV, Subtitle B and C, Public Law 100- 360; Medicare Catastrophic Coverage Repeal Act of 1989, Title II, Public Law 101-234; Omnibus Budget Reconciliation Act of 1989, Public Law 101- 239; Omnibus Budget Reconciliation Act of 1990, Public Law 101-508; Omnibus Budget Reconciliation Act of 1993, Public Law 103-66; Social Security Act Amendments of 1994, Public Law 103-432; Health Insurance Portability and Accountability Act of 1996, Public Law 104-191; Contract with America Advancement Act of 1996, Public Law 104-121; Balanced Budget Act of 1997, Public Law 105-33; Balanced Budget Refinement Act of 1999, Public Law 106-113; Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Public Law 106-554; Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173; Deficit Reduction Act of 2005, Public Law 109-171; Tax Relief and Health Care Act of 2006, Public Law 109-432.

Range of Approval/Disapproval Time

None.

Appeals

Telephone or visit the local Social Security Office or the Medicare payment organization responsible for the initial determination. The appeal process ranges from reviews, of the initial determinations to formal hearings and, in cases meeting certain criteria, reviews by Federal courts.

Renewals

None.

Assistance Considerations

Formula and Matching Requirements

None.

Length and Time Phasing of Assistance

None.

Post Assistance Requirements

Reports

None.

Audits

None.

Records

None.

Financial Information

Account Identification

20-8004-0-7-571.

Obigations

(Benefit Outlays) FY 07 $180,941,362,000; FY 08 est $187,935,000,000; and FY 09 est $194,351,000,000.

Range and Average of Financial Assistance

Generally, with exceptions for certain services, the beneficiary is responsible for meeting the annual $135 deductible before benefits may begin. Thereafter, Medicare pays a percent of the approved amount for the covered service. For many services, this percentage is 80 percent. For other services, the percentage that Medicare pays will vary from 100 percent to 50 percent depending upon the category of service.

Regulations, Guidelines, and Literature

Code of Federal Regulations, Title 20, Parts 401, 405, and 422; Title 42, Parts 401, 405, 407, 408, 410, 413, 416, and 417. "Your Medicare Handbook," and other publications are available from any Social Security Office without charge.

Information Contacts

Regional or Local Office

Consult Appendix IV of the Catalog for listing of Regional Offices.

Headquarters Office

Center for Beneficiary Choices, Centers for Medicare and Medicaid Services, Room C5-19-16, 7500 Security Boulevard, Baltimore, MD 21244. Telephone: (410) 786-3418.

Criteria for Selecting Proposals

None.