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The Federal MediCare Insurance Benefits

The Medicare program is one of the health insurance programs of the federal government for the elderly and disabled. It is administered by the Centers for Medicare and Medicaid Services (CMS).

Under the law, the program provides benefits for the following persons:

  • 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 people may be eligible and can also participate in the program. They 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 pays or reimburses qualifying health care providers for specific medical services. There are two separate programs:

  1. Medicare Part A - Also known as the Hospital Insurance Program, it provides beneficiaries with coverage for mostly hospital-related claims, such as:
    • Inpatient hospital care

    • Limited post-hospital skilled nursing facility

    • Home health care

    • Hospice care

  2. Medicare Part B – Known as the Supplementary Medical Insurance Program, it 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

Getting part B coverage is optional. But each program requires different deductible and co-payment amounts.

The program also offers new plans for eligible members under the MedicarePlus Choice Program. Under this, any individual who is entitled to benefits under Part A and enrolled under Part B, can choose from several types of health insurance plans. These include the following:

  • Coordinated Care Plans such as health maintenance organizations (HMOs), preferred provider organizations (PPO), and provider-sponsored organizations (PSO)

  • Private Fee-for-Service Plans

  • Medical Savings Accounts (MSAs)

Aside from that, there are other plans available for people under the federal program.

  1. Medigap Plans

    The Medicare supplemental insurance ("Medigap") plans provide coverage for:

    • Medicare deductible and co-payment amounts

    • Some health services not covered by Medicare

  2. Qualified Medicare Beneficiary program (QMB)
  3. Selected Low-Income Medicare Beneficiaries program ("SLMB")

The two latter plans may also provide payment for Medicare deductibles and co-payments to qualified individuals.

Medicare Exclusions

However, there are certain services not covered by the Medicare program. These include the following:

  • 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

The social security administration allows individuals to have legal representation when pursuing their claims and benefits. In fact, getting the services of a lawyer who is knowledgeable in medicare insurance benefits can improve your chances of obtaining the claims that you deserved.

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