Medicare-Supplementary Medical Insurance (93.774)
Program
93.774 Medicare-Supplementary Medical Insurance
Federal Agency
CENTERS FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Authorization
Social Security Act Amendments of 1965, Title XVIII, Part B, Public Law 89-97, as amended; Public Laws 90-248, 92-603, 93-233, 94-182, 95-210 and 95-292, 42 U.S.C. 1395 et seq.; Social Security Disability Amendments of 1980, Public Laws 96-265 and 97-248; Section 1, Public Law 98-21; Subtitle A, Public Law 98-369, as amended; Public Laws 98-460, 99-272, 99-509, and 100-203, 42 U.S.C. 1305 Note; Medicare Catastrophic Coverage Repeal Act of 1988, Title I, Subtitle B, Title II, Subtitles A and B, Title IV, Subtitle B and C, Public Law 100- 360; Medicare Catastrophic Coverage Repeal Act of 1989, Title II, Public Law 101-234; Omnibus Budget Reconciliation Act of 1989, 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; Health Insurance Portability and Accountability Act of 1996, Public Law 104-191; Contract with America Advancement Act of 1996, Public Law 104-121; Balanced Budget Act of 1997, Public Law 105-33; Balanced Budget Refinement Act of 1999, Public Law 106-113; Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Public Law 106-554.
Program Number
93.774
Last Known Status
Active
Objectives
To provide medical insurance protection for covered services to persons age 65 or over, to certain disabled persons and to individuals with chronic renal disease who elect this coverage.
Types of Assistance
Direct Payments for Specified Use.
Uses and Use Restrictions
Managed care benefits are paid on the basis on Medicare capitation rates. Fee-for-service benefits are paid on the basis of fee schedules or other approved amounts for services furnished by physicians and other suppliers of medical services to aged or disabled enrollees. Benefits are paid on the basis of prospective payment system for covered services furnished by participating providers such as hospitals and home health agencies.
Eligibility Requirements
Applicant Eligibility
All persons who are eligible for hospital insurance benefits (see 93.773) and persons age 65 and older who reside in the United States and are either citizens or aliens lawfully admitted for permanent residence who have resided in the United States continuously during the five years immediately preceding the month in the application for enrollment is filed, may voluntarily enroll for supplementary medical insurance (SMI). The beneficiary pays a monthly premium. In calendar year 2003, the base premium is $58.70. Some States and other third parties may pay the premium on behalf of qualifying individuals.
Beneficiary Eligibility
Persons age 65 and over, and persons under age 65 who qualify for hospital insurance benefits.
Credentials/Documentation
Proof of age, disability or lawful admission status. This program is excluded from coverage under OMB Circular No. A-87.
Application and Award Process
Preapplication Coordination
None. This program is excluded from coverage under E.O. 12372.
Application Procedure
Telephone or visit the local Social Security Office. Most persons entitled to hospital insurance are enrolled automatically for supplementary medical insurance. Since the program is voluntary, you may decline coverage. Persons not entitled to hospital insurance must file an application. This program is excluded from coverage under OMB Circular Nos. A-102 and A-110.
Award Procedure
After review of the application is completed, the applicant will be notified by mail.
Deadlines
Certain individuals may enroll during a special enrollment period (SEP) if they are covered under a group health plan (GHP) when first eligible to get Medicare: (1) individuals age 65 or older who are covered under a GHP based on their own or a spouse's current employment; and (2) disabled individuals under age 65 who are covered under a GHP based on their own or any family member's current employment. If the coverage of disabled individuals under age 65 was not through a large group health plan (LGHP), that is, a plan that covers employees of a least one employer that normally employs at least 100 employees, no family member other than a spouse qualifies for a special enrollment period. An SEP enrollment may occur during any month the individual is covered under the GHP based on current employment or, during the eight month period that begins the first month after employment or GHP coverage ends, whichever occurs first. Months of coverage under the GHP based on current employment are excluded from the calculation of the premium surcharge.
Range of Approval/Disapproval Time
Appeals
Telephone or visit the local Social Security Office or the Medicare payment organization responsible for the initial determination. The appeal process ranges from reviews, of the initial determinations to formal hearings and, in cases meeting certain criteria, reviews by Federal courts.
Renewals
Not applicable.
Assistance Considerations
Formula and Matching Requirements
This program has no statutory formula or matching requirements.
Length and Time Phasing of Assistance
Not applicable.
Post Assistance Requirements
Reports
None.
Audits
None.
Records
None.
Program Accomplishments
In fiscal year 2002, 37,932,000 persons were enrolled for supplementary medical insurance. In fiscal year 2003, the number of enrollees is estimated to be 38,358,000. In fiscal year 2004, the number of enrollees is estimated to be 38,2773,000.
Financial Information
Account Identification
20-8004-0-7-571.
Obligations
(Benefit Outlays) FY 02 $108,068,000; FY 03 $115,440,000; and FY 04 est $119,214,000.
Range and Average of Financial Assistance
Generally, with exceptions for certain services, the beneficiary is responsible for meeting the annual $100 deductible before benefits may begin. Thereafter, Medicare pays a percent of the approved amount for the covered service. For many services, this percentage is 80 percent. For other services, the percentage that Medicare pays will vary from 100 percent to 50 percent depending upon the category of service.
Regulations, Guidelines and Literature
Code of Federal Regulations, Title 20, Parts 401, 405, and 422; Title 42, Parts 401, 405, 407, 408, 410, 413, 416, and 417. "Your Medicare Handbook," and other publications are available from any Social Security Office without charge.
Related Programs
57.001, Social Insurance for Railroad Workers; 64.012, Veterans Prescription Service; 64.013, Veterans Prosthetic Appliances; 93.246, Health Centers Grants for Migrant and Seasonal Farmworkers; 93.773, Medicare_Hospital Insurance; 93.778, Medical Assistance Program; 96.001, Social Security_Disability Insurance.
Information Contacts
Regional or Local Office
Consult Appendix IV of the Catalog for listing of Regional Offices.
Headquarters Office
Center for Beneficiary Choices, Centers for Medicare & Medicaid Services, Room C5-19- 16, 7500 Security Boulevard, Baltimore, MD 21244. Telephone: (410) 786-3418.
Web Site Address
http://www.cms.hhs.gov/contracts/
Examples of Funded Projects
Not applicable.
Criteria for Selecting Proposals
Not applicable.
