93.773: Medicare: Hospital Insurance

Popular Name: Medicare

Objectives: To provide hospital insurance protection for covered services to persons age 65 or above, to certain disabled persons and to individuals with chronic renal disease.



Applicant Eligibility: Persons age 65 or over and certain disabled persons are eligible for hospital insurance protection. Nearly everyone who reached 65 before 1968 is eligible for hospital insurance, including people not eligible for cash Social Security benefits. A person reaching age 65 in 1968 or after, who is not eligible for cash benefits, needs some work credit to qualify for hospital insurance benefits. The amount of work credit needed depends on age. Hospital insurance (Medicare Part A) is also available to persons, age 65 or over, not otherwise eligible through payment of a monthly premium which is currently $289. A reduced Part A premium of $188 per month in 1996 is available to persons with 30 or more quarters paid into the social Security system, as well as to their spouse, surviving spouse or divorced spouse. The Part A premium is reduced by 30% in 1995, 35% in 1996, and by 40% in 1997. The reduction in Part A premium payments would also apply to the surviving spouse, or divorced spouse of an individual who had at least 30 quarters of coverage under the Social Security system. Federal employees began contributing toward medicare hospital insurance coverage beginning January 1983. Employees who worked prior to 1983 and who were employed during January 1983, can receive credit toward establishing Medicare eligibility, if necessary, for prior non-contributory quarters of Federal employment. State and local government employees not already in Social Security-covered positions and hired on or after April 1, 1986 also contribute toward Medicare hospital insurance coverage. Although States may request agreements to cover individuals employed prior to April 1, 1986, no credit is given toward establishing Medicare entitlement for prior employment. Persons under age 65 who have been entitled for at least 24 months to Social Security disability benefits, or for 29 consecutive months to railroad retirement benefits based on disability, are eligible for hospital insurance benefits. Also, most people who have chronic kidney disease and require kidney dialysis or transplant are eligible.

Beneficiary Eligibility: Persons age 65 or over and qualified disabled persons.

Credentials/Documentation: Proof of age or disability. This program is excluded from coverage under OMB Circular No. A-87.


Preapplication Coordination: None. This program is excluded from coverage under E.O. 12372.

Application Procedure: Phone or visit the local Social Security Office. Individuals entitled to Social Security or railroad retirement are enrolled without application. This program is excluded from coverage under OMB Circular Nos. A-102 and A-110.

Award Procedure: The individual will be notified by mail of enrollment, whether automatic or applied for.

Deadlines: None.

Range of Approval/Disapproval Time: Not applicable.

Appeals: Phone or visit the local Social Security Office or Medicare payment organization responsible for initial determination. The appeal process ranges from a reconsideration to a review by the Federal courts.

Renewals: Not applicable.

Criteria for Selecting Proposals: Not applicable.

Examples of Funded Projects: Not applicable.

Range & Average of Financial Assistance: Benefits may be paid based on the prospective payment amount or the reasonable costs of covered inpatient hospital services and based on the reasonable costs of covered post-hospital extended care services which are incurred during a benefit period. For benefit periods beginning in calendar year 1996, the beneficiary is responsible for a $736 inpatient hospital deductible, a $184 per day coinsurance amount for the 61st through 90th day of inpatient hospital care, a $368 per day coinsurance amount for inpatient hospital care during the 60 lifetime reserve days, and a $92.00 per day coinsurance amount for days 21 through 100 of care in a skilled nursing facility. Home health services are paid in full.


93.773 PROGRAM ACCOMPLISHMENTS: In fiscal year 1995, it is estimated that 36,934,000 persons were protected, and 8,080,000 had payments made on their behalf. In fiscal year 1996, it is estimated that the number protected will increase to 37,528,000. In fiscal year 1997, it is estimated that the number protected will increase to 38,073,000.



Type of Assistance: Direct Payments for Specified Use.

Obligations: (Benefit Outlays) FY 95 $113,402,509,000; FY 96 est $124,841,000,000; and FY 97 est $136,799,000,000.

Budget Account Number: 20-8005-0-7-571.

Authorization: Social Security Amendments of 1965, Title XVIII, Part A, Public Law 89-97, as amended, Public Laws 90-248, 92-603, 93-233, 94-182, 94-437 and 95-292, 42 U.S.C. 1395 et seq.; Social Security Disability Amendments of 1980, Public Law 96-265; Public Law 97-248; Section 1, Public Law 98-21; Subtitle A, Public Law 98-369; Public Law 98-460, 99-177, 99-272, 99-509, and 100-203, 42 U.S.C. 1305 Note; Medicare Catastrophic Coverage Act of 1988, Title I, Subtitles A and B, and Title IV, Subtitle B and C, Public Law 100-360; Catastrophic Coverage Repeal Act of 1989, Public Law 101-234; Omnibus Budget Reconciliation Act of 1989, Title VI, Subtitle A, 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.

Regulations, Guidelines, & Literature: Code of Federal Regulations, Title 20, Parts 401, 405 and 422; Title 42, Parts 400, 401, 405, 406, 409, 412, 417, and 418. "Your Medicare Handbook," SSA-79-10050, and other publications are available from any Social Security Office without charge.


Regional or Local Office: Consult Appendix IV of the Catalog for listing of Regional Offices.

Headquarters Office: Carol Walton, Director, Bureau of Program Operations, Health Care Financing Administration, Room S2-01-09, 7500 Security Blvd., Baltimore, MD 21244. Phone: (410) 786-8050. Use the same number for FTS.


Formula & Matching Requirements: This program has no statutory formula or matching requirements.

Length & Time Phasing of Assistance: Not applicable.

Uses & Use Restrictions: Hospital insurance benefits are paid to participating and emergency hospitals, skilled nursing facilities, home health agencies, and hospice agencies to cover the prospective payment amount or reasonable cost of medically necessary services furnished to individuals entitled under this program.


Reports: None.

Audits: None.

Records: None.

What now?

[ Top | Main Topics | Related Programs ]

[ Start a new search | Home Page ]