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Encyclopedia > Medicare (United States)
President Johnson signing the Medicare amendment. Harry Truman and his wife, Bess, are on the far right
President Johnson signing the Medicare amendment. Harry Truman and his wife, Bess, are on the far right

Medicare is a health insurance program administered by the United States government, covering people who are either age 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965 by President Lyndon B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card.[1] Image File history File linksMetadata Download high-resolution version (4850x3242, 2117 KB) File links The following pages on the English Wikipedia link to this file (pages on other projects are not listed): Lyndon B. Johnson Harry S. Truman Metadata This file contains additional information, probably added from the digital camera... Image File history File linksMetadata Download high-resolution version (4850x3242, 2117 KB) File links The following pages on the English Wikipedia link to this file (pages on other projects are not listed): Lyndon B. Johnson Harry S. Truman Metadata This file contains additional information, probably added from the digital camera... Elizabeth Virginia Wallace Truman (February 13, 1885 – October 18, 1982), often known as Bess Truman, was the wife of Harry S Truman and First Lady of the United States from 1945 to 1953. ... The term health insurance is generally used to describe a form of insurance that pays for medical expenses. ... The government of the United States, established by the United States Constitution, is a federal republic of 50 states, a few territories and some protectorates. ... is the 211th day of the year (212th in leap years) in the Gregorian calendar. ... Year 1965 (MCMLXV) was a common year starting on Friday (link will display full calendar) of the 1965 Gregorian calendar. ... LBJ redirects here. ... Social Security, in the United States, currently refers to the Federal Old-Age, Survivors, and Disability Insurance (OASDI) program. ... For other persons named Harry Truman, see Harry Truman (disambiguation). ...

A Medicare card, with several areas of the card obscured to protect privacy.
A Medicare card, with several areas of the card obscured to protect privacy.

Contents

Image File history File links Metadata No higher resolution available. ... Image File history File links Metadata No higher resolution available. ...

Administration

The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), administers Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and the Clinical Laboratory Improvement Amendments (CLIA). Along with the Departments of Labor and Treasury, CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Social Security Administration is responsible for determining Medicare eligibility and processing premium payments for the Medicare program. It has been suggested that Health Care Financing Administration be merged into this article or section. ... The United States Department of Health and Human Services, often abbreviated HHS, is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. ... Medicaid is the US health insurance program for individuals and families with low incomes and resources. ... The State Children’s Health Insurance Program (SCHIP) is a national program in the United States designed for families who earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance. ... The Clinical Laboratory Improvement Amendments (CLIA) are standards that regulate all laboratory testing performed on humans in the United States except clinical trials. ... The United States Department of Labor is a Cabinet department of the United States government responsible for occupational safety, wage and hour standards, unemployment insurance benefits, re-employment services, and some economic statistics. ... The U.S. Treasury building today. ... The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. ... The United States Social Security Administration (or SSA[1]) is an independent agency of the United States government established by a law currently codified at 42 U.S.C. Â§ 901. ...


The Chief Actuary of CMS is no longer responsible for providing all the accounting information and cost-projections to the Medicare Board of Trustees to assist them in assessing the financial health of the program. The Board isn't required by law to issue semi-annual reports on the financial status of the Medicare Trust Funds, and every report isn't required to contain a statement of actuarial opinion by the Chief Actuary.[2][3]


Since the beginning of the Medicare program, CMS has contracted to private companies to assist with administration. These contractors are commonly already in the insurance or health care area. Contracted processes include claims and payment processing, call center services, clinician enrollment, and fraud investigation.


Taxes Imposed to Finance Medicare

Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount of wages, etc., on which the Medicare tax could be imposed each year. Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the tax is 2.9% of net earnings from self-employment, and the entire amount is paid by the self-employed individual. This article is the current Taxation Collaboration of the Month. ... For other uses, see FICA (disambiguation). ... United States Social Security Card Social Security is a social insurance program administered by the Social Security Administration under the authority of the United States federal government. ... is the 365th day of the year (366th in leap years) in the Gregorian calendar. ... Year 1993 (MCMXCIII) was a common year starting on Friday (link will display full 1993 Gregorian calendar). ... is the 1st day of the year in the Gregorian calendar. ... Year 1994 (MCMXCIV) The year 1994 was designated as the International Year of the Family and the International Year of the Sport and the Olympic Ideal by the United Nations. ...


Cost

According to the 2004 "Green Book" of the House Ways and Means Committee, Medicare expenditures from the American government were $256.8 billion in fiscal year 2002. Beneficiary premiums are highly subsidized, and net outlays for the program, accounting for the premiums paid by subscribers, were $230.9 billion. The Committee on Ways and Means is a committee of the United States House of Representatives. ...


Eligibility

In general, individuals are eligible for Medicare if they (or their spouse) worked for at least 10 years in Medicare-covered employment and are at least 65 years old and are a citizen or permanent resident of the United States of America.


Individuals who are under 65 years old can also be eligible if they are disabled or have end stage renal disease. People under 65 and disabled must be receiving disability benefits from either Social Security or the Railroad Retirement Board for at least 24 months before automatic enrollment in Medicare occurs. Chronic renal failure - Wikipedia /**/ @import /skins/monobook/IE50Fixes. ... Social Security, in the United States, currently refers to the Federal Old-Age, Survivors, and Disability Insurance (OASDI) program. ... The Railroad Retirement Board (or RRB) was an agency of the United States government created in the 1930s which established a retirement benefit program for the countrys railroad workers. ...


Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states, for people under a certain income limit, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay for any drugs that are not covered by Part D. This article or section is in need of attention from an expert on the subject. ...


In 2005, Medicare provided health-care coverage for 42.6 million Americans. Enrollment is expected to reach 77 million by 2031, when the baby boom generation is fully enrolled.[4] For further information, see Baby boomer. ...


Benefits

The "Original Medicare" program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by Original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans are another way for beneficiaries to receive their Part A, B, and D benefits. Zoloft, an antidepressant and antianxiety medication A prescription drug is a licensed medicine that is regulated by legislation to require a prescription before it can be obtained. ... Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. ...


Part A: Hospital Insurance

Part A covers hospital stays (including stays in a skilled nursing facility) if certain criteria are met: For the town in the Republic of Ireland, see Hospital, County Limerick. ...

  1. The hospital stay must be at least three days, three midnights, not counting the discharge date.
  2. The nursing-home stay must be for something diagnosed during the hospital stay, or for the main cause of hospital stay. For instance, a hospital stay for a broken hip and then a nursing-home stay for physical therapy would be covered.
  3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision, then the nursing-home stay would be covered.
  4. The care being rendered by the nursing home must be skilled. Medicare Part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADLs) such as personal hygiene, cooking, cleaning, etc.

The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2007, $124.00 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. Long-term care (LTC) is a variety of services which help meet both the medical and non-medical need of people with a chronic illness or disability who cannot care for themselves for long periods of time. ... Activities of daily living (ADLs), is a way to describe the functional status of a person. ... Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss. ...


If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period.


Part B: Medical Insurance

Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not taking Part B if not actively working.


Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as lupron, and other outpatient medical treatments administered in a doctor's office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Radiography is the use of ionising electromagnetic radiation to view objects. ... Blood transfusion is the process of transferring blood or blood-based products from one person into the circulatory system of another. ... In medicine, dialysis is a type of renal replacement therapy which is used to provide an artificial replacement for lost kidney function due to renal failure. ... For a list of immunosuppressive drugs, see the transplant rejection page. ... “Transplant” redirects here. ... Chemotherapy is the use of chemical substances to treat disease. ...


Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prostheses following mastectomy, as well as one pair of eyeglasses following cataract surgery and oxygen for home use is also covered.[5] This is a term of art used to describe certain Medicare benefits, that is, whether Medicare may pay for the item. ... For the US TV series, see Cane (TV series). ... Wheelchair seating in a theater. ... A mobility scooter is a mobility aid similar to a wheelchair but configured like a motorscooter. ... The term disability, as it is applied to humans, refers to any condition that impedes the completion of daily tasks using traditional methods. ... A United States Army soldier plays table football with two prosthetic arms Jon Comer, professional skateboarder with a prosthetic leg. ... A United States soldier demonstrates table football with two transradial prosthetic limbs. ... A pair of breast prostheses with glued on nipples Breast prostheses are breast forms intended to simulate breasts. ... In medicine, mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. ... Glasses, spectacles, or eyeglasses are frames bearing lenses worn in front of the eyes, sometimes for purely aesthetic reasons but normally for vision correction or eye protection. ... Cataract surgery is the removal of the lens of the eye that has developed a cataract. ... Oxygen first aid kit showing a demand valve and a constant flow mask Oxygen therapy is the administration of oxygen as a therapeutic modality. ...


As with all Medicare benefits, Part B coverage is subject to medical necessity. Complex rules are used to manage the benefit, and advisories are periodically issued that describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor; Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Medical necessity is generally considered that which is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. ...


Part C: Medicare Advantage Plans

With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the Original Medicare plan (Parts A and B). These programs were known as "Medicare+Choice" or "Part C" plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the compensation and business practices changed for insurers who offer these plans, and "Medicare+Choice" plans became known as "Medicare Advantage" (MA) plans. Medicare Advantage plans are required to offer benefits that either mirror those offered by Original Medicare, or are richer than those which the beneficiary would receive through Original Medicare. In addition to enhanced benefits, Medicare Advantage plans typically replace the initial deductibles and 20% co-insurances that Original Medicare leaves with fixed-dollar amount co-pays; for example, Original Medicare covers 80% of the allowed amount of an in=patient hospital stay after the beneficiary has met their initial deductible, while the typical Medicare Advantage plan will cover 100% of the allowed amount for an in-patient hospital stay minus a fixed co-pay of something like $100.00, with no initial deductible. Medicare Advantage Plans that also include Part D Prescription Drug benefits are known as a Medicare Advantage Prescription Drug plan, or a MAPD. The Balanced Budget Act of 1997, Pub. ... The term health insurance is generally used to describe a form of insurance that pays for medical expenses. ... The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law No. ...


Part D: Prescription Drug Plans

Main article: Medicare Part D

Medicare Part D went into effect on January 1, 2006. Anyone with Part A or Part B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health-insurance companies. Unlike Original Medicare (Parts A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover and at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressants, and barbiturates.[6][7] Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.[8] Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. ... Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. ... is the 1st day of the year in the Gregorian calendar. ... Year 2006 (MMVI) was a common year starting on Sunday of the Gregorian calendar. ... The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law No. ... Alprazolam 2 mg tablets The benzodiazepines (pronounced , or benzos for short) are a class of psychoactive drugs considered minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties, which are mediated by slowing down the central nervous system. ... A cough medicine or antitussive is a medication given to people to help them stop coughing. ... Barbituric acid, the basic structure of all barbiturates Barbiturates are drugs that act as central nervous system depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. ...


It should be noted again that for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid will pay for drugs not covered by Part D of Medicare, such as benzodiazepines, and other restricted controlled substances. Alprazolam 2 mg tablets The benzodiazepines (pronounced , or benzos for short) are a class of psychoactive drugs considered minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties, which are mediated by slowing down the central nervous system. ...


Out-of-Pocket Costs

Neither Part A nor Part B pays for all of a covered person's medical costs. The program contains premiums, deductibles, and co-pays, which the covered individual must pay out-of-pocket. Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare. This article is actively undergoing a major edit. ... Look up Deductible in Wiktionary, the free dictionary. ... A copayment, or copay, is a flat dollar amount paid for a medical service by an insured person. ... Out-of-pocket expenses are direct outlays of cash which are not reimbursed. ...


Some people elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill the holes in Original Medicare (Parts A and B). These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. There is currently no CMS-approved supplemental coverage available to fill the Donut Hole, a coverage gap built into Medicare's Part D benefit. Medigap refers to various private supplemental health insurance plans sold in the United States to help pay for medical expenses not covered (or only partially covered) by Medicare. ... Within the Medicare Part D prescription drug program, the Donut Hole (or Doughnut Hole) is the phase of coverage in which all costs are covered by the enrollee rather than CMS. The term coverage gap is preferred by CMS and Prescription Drug Plans, but Donut Hole has been more widely...


Premiums

Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more quarters in which they paid Federal Insurance Contributions Act taxes. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may purchase Part A for a monthly premium of: Tax rates around the world Tax revenue as % of GDP Part of the Taxation series        The Federal Insurance Contributions Act (FICA) tax, a kind of payroll tax, is a United States employment tax imposed in an equal amount on employees and employers to fund federal programs for retirees, the disabled...

  • $226.00 per month (2007) for those with 30 to 39 quarters of Medicare-covered employment, or
  • $410.00 per month (in 2007) for those with less than 30 quarters of Medicare-covered employment and who are not otherwise eligible for premium-free Part A coverage.

All Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2007 is $93.50 per month. A new income-based premium schema has been in effect for 2007, wherein Part B premiums are higher for beneficiaries with incomes exceeding $80,000 for individuals or $160,000 for married couples. Depending on the extent to which beneficiary earnings exceed the base income, these higher Part B premiums are $105.80, $124.40, $142.90, or $161.40 for 2007, with the highest premium paid by individuals earning more than $200,000, or married couples earning more than $400,000. This article is actively undergoing a major edit. ... The word schema comes from the Greek word σχήμα (skhēma) that means shape or more generally plan. ...


Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks.


Part C and D plans may or may not charge premiums, at the programs' discretion. Part C plans may also choose to rebate a portion of the Part B premium to the member.


Deductibles and Co-insurance

Part A — For each benefit period, a beneficiary will pay:

  • A Part A deductible of $992 (in 2007) for a hospital stay of 1 to 60 days.
  • A $248 per day co-pay (in 2007) for days 61 to 90 of a hospital stay.
  • A $496 per day co-pay (in 2007) for days 91 to 150 of a hospital stay, as part of their limited Lifetime Reserve Days.
  • All costs for each day beyond 150 days.
  • Co-insurance for a Skilled Nursing Facility is $124.00 per day (in 2007) for days 21 through 100 for each benefit period.
  • A blood deductible of the first 3 pints of blood needed in a calendar year, unless replaced.

Part B — After a beneficiary meets the yearly deductible of $131.00 (in 2007), they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B. They are also required to pay an excess charge of 15% for services rendered by non-particpiating Medicare providers.


The deductibles and co-insurance charges for Part C and D plans vary from plan to plan.


Payment for Services

Medicare contracts with regional insurance companies who process over one billion fee-for-service claims per year. In 2003, Medicare accounted for almost 13% of the entire Federal budget. Based on the CMS projections, 33 cents of every dollar spent on health care in the U.S. is paid by Medicare and Medicaid (including state funding). Looked at from three different perspectives, 61 cents of every dollar spent on nursing homes, 47 cents of every dollar received by U.S. hospitals, and 27 cents of every dollar spent on physician services is funded by Medicare or Medicaid.


Reimbursement for Part A Services

For institutional care, such as hospital and nursing-home care, Medicare uses prospective payment systems. A prospective payment system is one in which the health-care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care used. The actual allotment of funds is based on a list of diagnosis-related groups (DRGs). The actual amount depends on the kind of diagnosis made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "upcoding," when a physician makes a more severe diagnosis to hedge against accidental costs. Diagnosis-Related Group #REDIRECT [[#REDIRECT Insert text#REDIRECT [[#REDIRECT Insert text]]]](DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use, developed for Medicare as part of the prospective payment system. ...


Reimbursement for Part B Services

Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991, the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.


The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. First, it introduced the Medicare Fee Schedule, which took effect in 1992. Second, it limited the amount Medicare non-providers could balance bill Medicare beneficiaries. Third, it introduced the Medicare Volume Performance Standards (MVPS) as a way to control costs.[9]


On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS). The MFS assigned Relative Value Units (RVUs) for each procedure from the Resource-Based Relative Value Scale (RBRVS). The Medicare reimbursement for a physician was the product of the RVU for the procedure, a Geographic Adjustment Factor (GAF) for geographic variations in payments, and a global Conversion Factor (CF) that converts RBRVS units to dollars. is the 1st day of the year in the Gregorian calendar. ... Year 1992 (MCMXCII) was a leap year starting on Wednesday (link will display full 1992 Gregorian calendar). ... Resource-Based Relative Value Scale (RBRVS) is a schema used to determine how much money medical providers should be paid. ...


From 1992 to 1997, adjustments to physician payments were adjusted using the MEI and the MVPS, which essentially tried to compensate for the increasing volume of services provided by physicians by decreasing their reimbursement per service.


In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR). This was done because of highly variable payment rates under the MVPS. The SGR attempts to control spending by setting yearly and cumulative spending targets. If actual spending for a given year exceeds the spending target for that year, reimbursement rates are adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVUs.


Since 2002, actual Medicare Part B expenditures have exceeded projections.


In 2002, payment rates were cut by 4.8%. In 2003, payment rates were scheduled to be reduced by 4.4%. However, Congress boosted the cumulative SGR target in the Consolidated Appropriation Resolution of 2003 (P.L. 108-7), allowing payments for physician services to rise 1.6%. In 2004 and 2005, payment rates were again scheduled to be reduced. The Medicare Modernization Act (P.L. 108-173) increased payments 1.5% for those two years.


In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109-362), and held physician payments in 2006 at their 2005 levels. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.


MFS has been criticized for not paying doctors enough because of the low conversion factor. By making adjustments to the MFS conversion factor, it is possible to pay all doctors more or less depending on how much money the person paying (CMS in this case) is willing to pay.[10]


Office Medication Reimbursement

Chemotherapy and other medications dispensed in a physician's office are reimbursed according to the Average Sales Price, a number computed by taking the total dollar sales of a drug as the numerator and the number of units sold nationwide as the denominator. The current reimbursement formula is known as "ASP+6" since it reimburses physicians at 106% of the ASP of drugs. Pharmaceutical-company discounts and rebates are included in the calculation of the ASP, and tend to reduce it. ASP+6 superseded Average Wholesale Price in 2005, after a 2004 front-page New York Times article drew attention to the inaccuracies of Average Wholesale Price calculations. Average Wholesale Price (AWP) reimbursement tended to be more favorable for physicians, since it was an arbitrary number provided by the pharmaceutical company to CMS. Since the change, some outpatient chemotherapy drugs are "underwater," since the wholesale price from drug distributors may be higher than ASP+6 for some drugs.[citation needed] Stakeholders are involved in active discussions with the United States Congress to address this issue.[citation needed] Chemotherapy is the use of chemical substances to treat disease. ... Type Bicameral Houses Senate House of Representatives President of the Senate President pro tempore Dick Cheney, (R) since January 20, 2001 Robert C. Byrd, (D) since January 4, 2007 Speaker of the House Nancy Pelosi, (D) since January 4, 2007 Members 535 plus 4 Delegates and 1 Resident Commissioner Political...


Criticism

Medicare faces continuing financial issues. In its 2006 annual report to Congress, the Medicare Board of Trustees reported that the program's hospital insurance trust fund could run out of money by 2018. The trustees have made such projections in the past, but this one was bleaker than the outlook reported in 2005.[11]


The fundamental problem is that the ratio of workers paying Medicare taxes to retirees drawing benefits is shrinking at the same time that the price of health care services per person is increasing.[12][13] Currently there are 3.9 workers paying taxes into Medicare for every older American receiving services. By 2030, as the baby boom generation retires, that is projected to drop to 2.4 workers for each beneficiary. Medicare spending is expected to grow by about 7 percent per year for the next 10 years.[14] As a result, the financing of the program is out of actuarial balance, presenting serious challenges in both the short-term and long-term.[15]


Part of the cost of Medicare is fraud, which government auditors estimate costs Medicare billions of dollars a year.[16][17] The Government Accountability Office lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.[18] General Accounting Office headquarters, Washington, D.C. The Government Accountability Office (GAO) is the non-partisan audit, evaluation, and investigative arm of Congress, and an agency in the Legislative Branch of the United States Government. ...


Popular opinion surveys show that the public views Medicare’s problems as serious, but not as urgent as other concerns. In January 2006, the Pew Research Center found 62 percent of the public said addressing Medicare’s financial problems should be a high priority for the government, but that still put it behind other priorities.[19] Surveys suggest that there’s no public consensus behind any specific strategy to keep the program solvent.[20]


A study by the Government Accountability Office evaluated the quality of responses given by Medicare-contractor customer-service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer-service representatives was 15%.[21]


Legislation and Reform

President Bill Clinton attempted an overhaul of Medicare through his health care reform plan in 1993-1994, but was unable to get the legislation passed by Congress. The Balanced Budget Act of 1997, Pub. ... The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law No. ... William Jefferson Bill Clinton (born William Jefferson Blythe III[1] on August 19, 1946) was the 42nd President of the United States, serving from 1993 to 2001. ... The Clinton health care plan was a 1993 healthcare reform package proposed by the administration of Bill Clinton, then sitting President of the United States. ...


In 2003 the Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which President George W. Bush signed into law on December 8, 2003. Part of this legislation included filling gaps in prescription-drug coverage left by the Medicare Secondary Payer Act that was enacted in 1980. The 2003 bill strengthened the Workers' Compensation Medicare Set-Aside Program (WCMSA), which is monitored and administered by CMS. Type Bicameral Houses Senate House of Representatives President of the Senate President pro tempore Dick Cheney, (R) since January 20, 2001 Robert C. Byrd, (D) since January 4, 2007 Speaker of the House Nancy Pelosi, (D) since January 4, 2007 Members 535 plus 4 Delegates and 1 Resident Commissioner Political... The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law No. ... George Walker Bush (born July 6, 1946) is the forty-third and current President of the United States of America, originally inaugurated on January 20, 2001. ... is the 342nd day of the year (343rd in leap years) in the Gregorian calendar. ... Year 2003 (MMIII) was a common year starting on Wednesday of the Gregorian calendar. ...


On August 1, 2007, Democrats pushed through legislation in the United States Congress making deep cuts in federal payments to Medicare health maintenance organizations, defying a veto threat from President Bush. [22] Type Bicameral Houses Senate House of Representatives President of the Senate President pro tempore Dick Cheney, (R) since January 20, 2001 Robert C. Byrd, (D) since January 4, 2007 Speaker of the House Nancy Pelosi, (D) since January 4, 2007 Members 535 plus 4 Delegates and 1 Resident Commissioner Political... This article does not cite any references or sources. ...


Legislative Oversight

Cameral Body Committee Leader
Joint House/Senate Joint Economic Committee Charles Schumer
House House Committee on Ways and Means Charles Rangel
House House Committee on Ways and Means Subcommittee on Health Pete Stark
House House Committee on Energy and Commerce John Dingell
House House Committee on Energy and Commerce Subcommittee on Health Frank Pallone
House House Committee on Energy and Commerce Subcommittee on Oversight and Investigations Bart Stupak
House House Committee on Appropriations David Obey
House House Committee on Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies David Obey
House House Small Business Committee Nydia Velazquez
House House Budget Committee John Spratt
House House Committee on Ways and Means Subcommittee on Health Fortney Pete Stark
Senate Senate Committee on Finance Max Baucus
Senate Senate Special Committee on Aging Herb Kohl
Senate Senate Committee on Appropriations Robert Byrd
Senate Senate Committee on Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies Tom Harkin
Senate Senate Committee on Homeland Security and Governmental Affairs Joe Lieberman
Senate Senate Committee on Homeland Security and Governmental Affairs Subcommittee on Oversight of Government Management, the Federal Workforce, and the District of Columbia Daniel Akaka
Senate Senate Committee on Health, Education, Labor and Pensions Ted Kennedy
Senate Senate Committee on Health, Education, Labor and Pensions Subcommittee on Retirement Security and Aging Barbara Mikulski
Senate Senate Budget Committee Kent Conrad
Senate Senate Committee on Homeland Security and Governmental Affairs Subcommittee on Federal Financial Management, Government Information, and International Security Thomas Carper
This table incorporates information available on the CMS Website[23]

The Joint Economic Committee is one of only four joint committees of the U.S. Congress. ... Charles Ellis Chuck Schumer (born November 23, 1950) is a Jewish American politician. ... The Committee on Ways and Means is a committee of the United States House of Representatives. ... Charles Bernard Rangel Charles Bernard Rangel (born June 11, American politician. ... The Committee on Ways and Means is a committee of the United States House of Representatives. ... Stark delivers his response to President George W. Bushs 2005 State of the Union address. ... The U.S. House Commerce Committee on Energy and Commerce residing at 2125 Rayburn House Office Building in Washington, DC is the oldest (208 years) legislative standing committee in the U.S. House of Representatives. ... Rep. ... The U.S. House Energy Subcommittee on Health is a subcommittee within the House Commitee on Energy and Commerce. ... Frank Pallone Jr. ... Bartholomew Thomas Bart Stupak (born February 29, 1952), American politician, has been a Democrat in the United States House of Representatives since 1993, representing Michigans 1st congressional district (map). ... The Committee on Appropriations, or Appropriations Committee (often referred to as simply Appropriations, as in Hes on Appropriations) is a committee of the United States House of Representatives. ... David Ross Obey (born October 3, 1938) is an American politician. ... The Subcommittee on Labor, Health and Human Services, Education, and Related Agencies is a subcommittee within the House Appropriations Committee. ... David Ross Obey (born October 3, 1938) is an American politician. ... The United States House Committee on Small Business is a standing committee of the United States House of Representatives. ... Nydia Margarita Velazquez (born (March 28, 1953) in Yabucoa, Puerto Rico), became the first Puerto Rican woman to be elected to the U.S. House of Representatives. ... The U.S. House Committee on the Budget, commonly known as the House Budget Committee, is a standing committee of the United States House of Representatives, the lower house of Congress. ... John McKee Spratt, Jr. ... The Subcommittee on Health is a subcommittee of the Committee on Ways and Means in the United States House of Representatives. ... Fortney Hillman Pete Stark Jr. ... The U.S. Senate Committee on Finance (or, less formally, Senate Finance Committee) is a standing committee of the United States Senate. ... Max Sieben Baucus (b. ... The United States Senate Special Committee on Aging was initially established in 1961 as a temporary committee; it became a permanent committee in 1977. ... This article refers to Sen. ... The U.S. Senate Committee on Appropriations is a standing committee of the United States Senate. ... Robert Carlyle Byrd (born November 20, 1917) is the senior United States Senator from West Virginia and a member of the Democratic Party. ... The United States Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies is a subcommittee of the United States Senate Committee on Appropriations. ... Thomas Richard Tom Harkin (born November 19, 1939) is a liberal Democratic Senator from Iowa, serving in his fourth senate term. ... The United States Senate Committee on Homeland Security and Governmental Affairs has jurisdiction over matters related to the Department of Homeland Security and other homeland security concerns, as well as the functioning of the government itself, including the National Archives, budget and accounting measures other than appropriations, the Census, the... Joseph Isadore Joe Lieberman (born February 24, 1942) is a United States Senator from Connecticut. ... Daniel Kahikina Dan Akaka (Chinese: 阿卡卡 李碩, Hanyu pinyin: akaka lishuo) (born September 11, 1924) is a U.S. Senator from Hawaiʻi and a member of the Democratic Party. ... The United States Senate Committee on Health, Education, Labor, and Pensions (HELP) has jurisdiction over matters relating to health, education, labor, and pensions. ... For other persons named Ted Kennedy, see Ted Kennedy (disambiguation). ... Barbara Ann Mikulski (born July 20, 1936), a member of the Democratic Party, is the current Class 3 United States Senator representing the State of Maryland. ... The United States Senate Committee on Budget was established in 1974 by the Congressional Budget and Impoundment Control Act. ... Kent Conrad (born on March 12, 1948) is a United States senator from North Dakota. ... Thomas Richard Carper (born January 23, 1947) is a United States politician who has been a U.S. Senator from Delaware since 2001. ...

See Also

The Administration on Aging agency in the United States Department of Health and Human Services (HHS) conducts statistical activities in support of the research, analysis, and evaluation of programs to meet the needs of an aging population. ... Long-term care (LTC) is a variety of services which help meet both the medical and non-medical need of people with a chronic illness or disability who cannot care for themselves for long periods of time. ... Medicare is Australias publicly-funded universal health care system, operated by the government authority Medicare Australia. ... The term medicare (in lowercase) (French: assurance maladie) is the unofficial name for Canadas universal public health insurance system. ... This article or section is in need of attention from an expert on the subject. ... Medigap refers to various private supplemental health insurance plans sold in the United States to help pay for medical expenses not covered (or only partially covered) by Medicare. ... NHS redirects here. ... Quality Improvement Organizations (QIOs) monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries. ... The Railroad Retirement Board (or RRB) was an agency of the United States government created in the 1930s which established a retirement benefit program for the countrys railroad workers. ... Stark law, actually two separate provisions, governs physician self-referral for Medicare and Medicaid patients. ...

References

  1. ^ http://www.ssa.gov/history/lbjsm.html
  2. ^ "What Is the Role of the Federal Medicare Actuary?," American Academy of Actuaries, January 2002
  3. ^ "Social Insurance," Actuarial Standard of Practice No. 32, Actuarial Standards Board, January 1998
  4. ^ http://www.cms.hhs.gov/ReportsTrustFunds
  5. ^ http://www.uihealthcare.com/topics/aging/agin3390.html Medicare: Part A & B
  6. ^ http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PartDDrugsPartDExcludedDrugs_04.19.06.pdf
  7. ^ http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf
  8. ^ http://oig.hhs.gov/oas/reports/region6/60600022.pdf
  9. ^ Lauren A. McCormick, Russel T. Burge. Diffusion of Medicare's RBRVS and related physician-payment policies - the resource-based relative value scale - Medicare Payment Systems: Moving Toward the Future Health-Care Financing Review. Winter, 1994.
  10. ^ Medicare's Physician Payment Rates and the Sustainable Growth Rate.(PDF) CBO TESTIMONY Statement of Donald B. Marron, Acting Director. July 25, 2006.
  11. ^ http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1846
  12. ^ http://www.publicagenda.org/issues/factfiles_detail.cfm?issue_type=medicare&list=2
  13. ^ http://www.publicagenda.org/issues/factfiles_detail.cfm?issue_type=medicare&list=12
  14. ^ 2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplimentary Medical Insurance Trust Funds, 1 May 2006 (PDF). Retrieved on July 21, 2006.
  15. ^ Medicare’s Financial Condition: Beyond Actuarial Balance," American Academy of Actuaries, April 2007 http://www.actuary.org/pdf/medicare/trustees_07.pdf
  16. ^ http://www.gao.gov/docdblite/summary.php?rptno=GAO-05-656&accno=A37738
  17. ^ http://www.gao.gov/new.items/d02546.pdf
  18. ^ "High-Risk Series: An Update" U.S. Government Accountability Office, January 2003 (PDF). Retrieved on July 21, 2006.
  19. ^ http://www.publicagenda.org/issues/pcc_detail.cfm?issue_type=medicare&list=1
  20. ^ http://www.publicagenda.org/issues/red_flags.cfm?issue_type=medicare
  21. ^ http://www.gao.gov/new.items/d011141t.pdf
  22. ^ http://news.yahoo.com/s/ap/20070801/ap_on_go_co/congress_children_s_health??
  23. ^ http://www.cms.hhs.gov/OfficeofLegislation/COI/list.asp CMS Website, accessed 2/15/07

To meet Wikipedias quality standards, this article or section may require cleanup. ... Year 1994 (MCMXCIV) The year 1994 was designated as the International Year of the Family and the International Year of the Sport and the Olympic Ideal by the United Nations. ... is the 206th day of the year (207th in leap years) in the Gregorian calendar. ... Year 2006 (MMVI) was a common year starting on Sunday of the Gregorian calendar. ... To meet Wikipedias quality standards, this article or section may require cleanup. ...

External Links

Governmental Links - Current

  • CMS official web site at cms.hhs.gov
    • Medicare at cms.hhs.gov
  • Medicare.gov — the official website for people with Medicare
    • Official Medicare publications at Medicare.gov — includes official publications about current Medicare benefits
    • Information about the 1-800-MEDICARE helpline from Medicare.gov — a 24X7 toll-free number to call with questions about Medicare
    • Medicare Modernization Act at Medicare.gov
    • Medicare Plan Choices at Medicare.gov — basic information about plan choices for Medicare beneficiaries, including MA Plans
    • Prescription Drug Coverage homepage at Medicare.gov — a central location for Medicare's web-based information about the Part D benefit
      • Landscape of plans — state-by-state breakdown of all plans available in an area, both stand-alone PDPs, as well as MA-PD plans
  • MyMedicare.gov — Medicare's secure online service where beneficiaries can access their own personal Medicare information

A toll-free telephone number (or Freephone number in the UK) is a special telephone number, in which the calling party is not charged for the call by the telephone operator. ...

Governmental Links - Historical

Non-governmental Links


  Results from FactBites:
 
Medicare and Medicaid - MSN Encarta (949 words)
Medicare and Medicaid, programs of medical care for the aged and for the needy, respectively, in the United States.
Medicare is the popular name for the federal health insurance program for persons 65 years of age and over.
Medicare costs are met by Social Security contributions, monthly premiums from participants, and general revenues.
  More results at FactBites »

 
 

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