- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 2: Medicare Basics
Medicare Eligibility and Premiums
The following groups of people are eligible for Medicare:
- Individuals aged 65 or older (or their spouse) who have worked at least 40 quarters, or ten years, in Medicare-covered employment. These do not have to be ten consecutive years. A husband or wife can become eligible for Medicare based on their spouse’s employment history.
- Individuals under age 65 receiving disability benefits under Social Security or Railroad Retirement for more than 24 months
- Effective 7/1/2001, the 24-month waiting period for Medicare coverage for those individuals with ALS (Lou Gehrig’s disease) is waived. Entitlement begins with the first month of the Social Security Administration’s determination of eligibility for disability insurance benefits.
- Individuals with permanent kidney failure who require maintenance dialysis or a kidney transplant, ESRD.
- Certain Government employees and certain members of their families who have been disabled for more than 29 months.
Depending on how long a person has worked in Medicare-covered employment (has had Medicare taxes taken out of their paychecks), individuals can be entitled to receive Medicare Part A premium-free. As stated above, a person must have 40 quarters, sometimes called “credits,” of Medicare-covered employment to receive Medicare without having to pay a premium for Part A.
Individuals who do not have enough credits, who are sometimes called “voluntary enrollees,” may purchase Medicare Part A for a monthly premium payment. When voluntary enrollment takes place more than one month after a person’s initial enrollment period for Part A benefits, the monthly premium increases by ten percent.
Part B coverage is not premium-free; all enrollees are subject to a monthly premium. As of January 2007, Medicare beneficiaries with higher incomes are required to pay a greater portion of their Part B premium costs. This will be accomplished through an income-related increase that will be added to the standard Medicare Part B monthly premium, plus any applicable increases to the premium for late enrollment or reenrollment.
The new income-related premium is a requirement of the Medicare Modernization Act (MMA) of 2003, Section 811, Pub. L. 108-173 (12/8/2003). The Deficit Reduction Act (DRA) of 2005, Section 5111, Pub. L. 109-171, further provided that the payment of the full amount of the premium increase be phased in starting in 2007, to be completed in 2009. When enrollment takes place more than 12 months after a person’s initial enrollment period, the monthly premium increases by ten percent for each full 12-month period during which the individual could have been enrolled but was not.
Revised 1/2021