Medicare Basics
Medicare was established in 1965 and is currently the world's largest insurance program.
The Centers for Medicare & Medicaid Services (CMS) administers Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP). CMS also oversees the day-to-day operations of Medicare contractors.
The Social Security Administration (SSA) determines Medicare eligibility. To be eligible for Medicare, an individual must meet one of the following requirements:
• 65 or older
• Under 65 with certain disabilities
• Any age with End-Stage Renal Disease (ESRD)
There are four basic parts of Medicare:
Part A (Hospital Insurance)
• Hospital
• Skilled Nursing Facility (SNF)
• Home Health
• Hospice
Part B (Medicare Insurance)
• Doctor
• Ambulance
• Lab, X-Ray
• Durable Medical Equipment (DME) & Supplies
Part C (Medicare Advantage)
• Receiving Parts A and B (and often D) through a private plan
Part D (Rx Drug Coverage)
• Only available through private plans
If an individual is already receiving SSA benefits, enrollment in Part A and Part B is automatic when he/she becomes eligible (age 65 or 25 months of disability payments). If an individual is not receiving SSA benefits, he/she can contact SSA to enroll:
• We recommend individuals to contact SSA within three months of turning 65
• An individual can enroll in Medicare without retiring
Individuals who have to sign up for Part A and/or Part B may enroll during designated enrollment periods:
• Initial Enrollment Period
• General Enrollment Period
• Special Enrollment Period
Part A is free if an individual has 40 quarters of work history. If you do not have the work history, you can enroll in Part A (and pay a monthly premium) if you meet the following conditions:
• 65 years or older
• United States citizen or lawfully admitted for permanent residence for five years
The Part B monthly premium is automatically deducted from a beneficiary's SSA check or billed to the beneficiary.
As introduced earlier, there are four parts of Medicare. Select each of the links below for a closer look at each part.
• Part A
• Part B
• Part C
• Part D
Medicare does not cover all procedures. Select the link below for a list of common exclusions for traditional Medicare.
• Exclusions
A Medicare card is issued to every person entitled to Medicare benefits. Each card contains the following information:
• Name (as it appears on Social Security records)
• Medicare Health Insurance Claim (HIC) number
• Medicare Part A and/or B entitlement dates
Collecting the correct insurance information is very important to ensure correct billing. It is a good practice to ask for all beneficiary insurance cards. Beneficiaries who opt to enroll in an MA plan may have two insurance cards.
Verifying Medicare eligibility is a daily task in medical facilities and it's imperative this is completed without violating the beneficiary's privacy. Part B providers can verify beneficiary eligibility through the Interactive Voice Response (IVR).
