The State of Utah, Department of Human Services, Division of Aging and Adult Services, Health Insurance Information Program, is committed to making available as much information as possible to ensure beneficiaries make informed choices about their health insurance.
The Health Insurance Information Program does not determine eligibility for, or administer any of the services mentioned in this web site.Please contact the appropriate agencies directly for your individual determination of eligibility and services.
Medicare Part A plans are administered by the federal Centers for Medicare and Medicaid Services.
Eligibility for Medicare Part A is determined by Social Security Administration.
General Information Included on this Web Page
- Prospective Payment System (PPS)
- Quality of Care
- Waiver of Liability
Three Categories of Eligibility for Medicare Part A
- Nearly everyone age 65 and over.
- Disabled individuals of any age who have received 24 months of Social Security Disability benefits.
- Persons of any age with end-stage renal (kidney) disease.
Role of Social Security Administration
- Determines eligibility and handles enrollment.
- Those eligible for automatic enrollment are notified of Part A coverage upon reaching the age of 65; otherwise, application for Social Security cash benefits or hospital insurance enrolls the person in Part A.
- Upon reaching the age of 65, those eligible for Part A coverage, but required to pay premiums, can enroll through the local Social Security office.
- The local Social Security office is the community resource for information and procedures surrounding eligibility and enrollment.
- The local telephone number can be found in the U.S. government listings of the telephone directory.
- The national toll free number for Social Security Administration is 1-800-772-1213.
- Automatically Eligible Persons, (no monthly Part A premium for the following):
- Those entitled to and receiving Social Security cash benefits through early retirement, or disability, based on employee Social Security contributions, and widow(er)s and spouses of persons who qualify for Social Security cash benefits, are automatically enrolled in Medicare Part A upon turning 65. Also included are federal retirees who retired after 1982.
- A card is mailed approximately three months before 65th birthday to those already receiving cash benefits. The beneficiary signs the card and keeps it. The card is returned to Social Security only if the senior does not want Part B Medical Insurance, (See our Medicare B page for more info.)
- Those eligible for, but not receiving, Social Security cash benefits upon turning 65 must apply for cash benefits, or for hospital insurance (Part A) to receive them.
- Persons age 65 and older who did not pay Social Security contributions, or were not "grandfathered" into the program by attaining 65 by 1967 may apply for Medicare Part A.
- Individuals choosing to enroll in Part A must also be enrolled in Part B of Medicare which also carries a monthly premium.
- Disabled persons who lose Medicare because their status as disabled ended solely because their earnings exceeded "substantial gainful activity limits" may now purchase Parts A and B coverage. (Effective July 1990.)
- The Part A monthly premium increases by 10 percent if the Voluntary Enrollee delays enrollment for 12 months or more. This penalty applies only to Voluntary Enrollees. If the delay is for two years or more, the penalty continues for two years.
- Provisions for those individuals eligible for, but not receiving Social Security cash benefits
- Application for enrollment can be made as many as three months in advance of the eligible person's 65th birthday. (Generally, this type of enrollment can occur at any time of the year and still be considered "open enrollment", as long as it occurs during the Seven-month time period surrounding the 65th birthday, [three months prior to the month of the 65th birthday, the month of the 65th birthday, and three months following the month of the 65th birthday].)
- Persons eligible for, but not receiving, cash benefits can get retroactive hospital coverage under Part A. Retroactive coverage may begin on the first day of the month in which the beneficiary turned 65, but not more than six months before the month in which application for hospital benefits is filed, (12 months for disabled widow[er]s).
- Provisions for Persons Who Must Pay a Premium for Part A Benefits
- Initial Enrollment
- Seven-month time period surrounding the 65th birthday, (three months prior to the month of the 65th birthday, the month of the 65th birthday, and three months following the month of the 65th birthday).
- The effective date for coverage during the initial enrollment period depends on the enrollment date.
- If a person enrolls during the three months prior to the month the 65th birthday occurs, coverage begins on the first day of the month in which the person turns 65.
- If a person enrolls during the month the 65th birthday occurs, coverage begins on the first day of the month immediately following the birthday month.
- If a person enrolls during the three months following the month of the 65th birthday, coverage begins two months after enrolling when enrollment occurs in the first month following the birthday month, or coverage begins three months after enrolling when enrollment occurs in the second or third month following the birthday month.
- General Enrollment
- The first three months, (January, February, March), of any year following the year of the 65th birthday. Coverage will be effective July 1 of that year.
- Penalties for late enrollment are imposed for enrollments that are made more than one year past the month of the person's 65th birthday.
In general, the Part A premium increases 10 percent for each 12-month period that enrollment, (effective coverage), is delayed past the seven-month initial enrollment period. There is no cap on this penalty; (e.g., a delay of five years will result in a penalty of 50 percent).
- Special Enrollment
- At any time while the individual is covered by an employer group health coverage plan based on his or her own , or a spouse's current employment, (not retired), OR, during the month of, or any of the seven months following the termination of, the employer group health coverage plan.
- Coverage is effective the month of enrollment or any later month designated by applicant.
- There is no penalty for months the individual was eligible for Medicare but did not enroll because of an employer group health plan based on current employment of self or spouse.
The benefit period is a way of measuring a beneficiary's use of inpatient hospital and skilled nursing facility services. It is a time period in which a beneficiary is entitled to a certain amount of Part A coverage for the health care he or she receives.
- Begins on the first day a beneficiary receives inpatient hospital care and ends after an individual has been out of a hospital or, in some cases, a skilled nursing facility for 60 consecutive days.
- Original benefit period continues if the beneficiary returns to the hospital or skilled nursing facility before 60 consecutive days have elapsed.
The initial amount the beneficiary is responsible for paying before Medicare coverage begins. Deductibles are determined by Medicare, the plan is administered by the Centers for Medicare and Medicaid Services.
A percentage or dollar amount of covered expense which the beneficiary is required to pay. Co-Insurance determinations are made by Medicare, the plan is administered by the Centers for Medicare and Medicaid Services.
Reasonable and Necessary Care
Part A pays only for services determined to be "reasonable and necessary" in the diagnosis or treatment of a specific illness or injury. Utilization Review Committees, Peer Review Organizations, and Intermediaries determine what care is considered reasonable and necessary. To clarify if services you are receiving are considered "reasonable and necessary", contact your physician directly.
Home Health Agency, (HHA)
A public or private agency, (non-profit or proprietary), that specializes in providing skilled nursing services and other therapeutic services, such as physical therapy, in the home.
A hospice is an establishment or a program that provides for the physical and emotional needs of a terminally ill beneficiary.
Medicare + Choice
Congress created the Medicare + Choice program to let more private insurance companies offer coverage to people in Medicare. If you have questions regarding this program please contact Medicare directly.
Peer Review Organizations, (PROs)
Peer Review Organizations are non-governmental, physician-sponsored organizations contracted with Medicare to monitor the hospital Prospective Payment System and perform utilization and quality review functions. There is a PRO for each state.HealthInsight serves the State of Utah.
Part A is designed to pay part of the costs of four types of health services:
- Inpatient hospital stays
- Skilled Nursing Facility Care
- Home Health Care
- Hospice Care
Part A does not pay for some services:
- The number of days for inpatient hospital or Skilled Nursing Facility care in a benefit period is limited.
- The beneficiary is responsible for paying the hospital deductible and co-insurance for hospital and Skilled Nursing Facility care. The hospital deductible is per benefit period.
- Medicare pays only for care that is considered "reasonable and necessary" for the diagnosis or treatment of illness or injury, as defined by Medicare regulations. The plan is administered by the Centers for Medicare and Medicaid Services.
- Items or services provided free of charge, (i.e., free Department of Veterans Affairs care for eligible beneficiaries), or paid for by government agency, (i.e., workers' compensation).
Part A can help pay for inpatient hospital care if all of the following conditions are met:
- A physician prescribes inpatient hospital care for the treatment of an illness or injury;
- The beneficiary requires and receives the kind of care that can be provided only in a hospital;
- The hospital is participating in Medicare; and
- The Utilization Review Committee of the hospital or the Peer Review Organization does not disapprove the stay.
- Part A can help pay for home health care if all of the following conditions are met:
- The care needed is part-time or intermittent skilled nursing care, physical therapy, or speech therapy;
- The beneficiary requiring the care is confined to his or her home, but not necessarily bedridden. (An individual is considered to be homebound if there is a condition that restricts the ability to leave the home except with the assistance of a supportive device, [i.e., wheelchair], the use of special transportation, or the assistance of another person for a short, infrequent trip for medical treatment.);
- A physician determines the beneficiary needs home health care and sets up a plan for home health care;
- The home health agency providing the services is participating in Medicare; and
- There is at least one predictable skilled nursing care, physical therapy, speech therapy, or occupational therapy service every 60 days.
Medicare will pay some of the costs toward hospice care if all of the following conditions are met.
- The beneficiary is eligible for Medicare Part A;
- A physician and hospice medical director certifies or recertifies that the beneficiary is terminally ill, (diagnosed as having six months or less to live);
- A beneficiary signs a statement choosing to receive care from a hospice instead of standard Medicare benefits for the terminal illness; and
- Care is provided by a Medicare-certified hospice program. (Fewer than half of the 1500 hospices in the U.S. are Medicare-certified).
Under the former system of Medicare reimbursement for hospitalization, a patient entered the hospital, the hospital billed Medicare, the hospital was reimbursed according to "reasonable cost", and the hospital billed the patient only for deductibles, co-insurance, and non-covered services. The more services and the longer stays, the more hospitals could bill Medicare. Hence, the greater their reimbursement would be. In an attempt to correct this problem, Congress passed legislation in 1983 which created the prospective inpatient admission according to a predetermined formula.
Skilled Nursing Facilities
Formerly, skilled nursing facilities were paid based on "reasonable cost". Starting January 1, 1999 all skilled nursing facilities payments will be based on a prospective payment system. It is not the same system as inpatient hospital care but is based on a thorough evaluation of the beneficiaries medical condition and services.
Under the old payment system, the facility would charge a certain amount for its service, then Medicare would pay according to how much the services actually cost. The beneficiary was then responsible for 20 percent of the amount the facility charged. Many times this meant the beneficiary would pay half the total payment to the hospital.
Under the new Outpatient Prospective Payment System, whenever Medicare receives a claim for outpatient services from a hospital or Community Mental Health Center, it will pay for each service at an approved amount.
The major change for beneficiaries under this new payment system is the co-insurance amounts for which they will be responsible. In most cases it will be less than in the past, although sometimes it may be more.Health Care Financing Administration
The Prospective Payment System is administrated by the Centers for Medicare and Medicaid Services.
Peer Review Organizations
A Peer Review Organization is designated by Medicare to investigate complaints about the quality of medical care provided in hospitals, skilled nursing facilities, ambulatory surgery centers, home health agencies, comprehensive outpatient rehabilitation facilities, emergency rooms, hospices, hospital outpatients areas, outpatient physical therapy and speech/language pathology services, rural primary care hospitals, skilled nursing facility swing beds within inpatient rural primary care hospitals and specialty hospitals, (e.g., psychiatric and rehabilitation), if the care is, or normally would be, covered by Medicare and the facility is a Medicare provider.
The Peer Review Organization designated in Utah is HealthInsight, if you need to file a complaint regarding the quality of your medical care, please contact HealthInsight directly.Right to Appeal a Hospital Issued Notice of Non-Coverage
As a Medicare Part A participant, a beneficiary has the right to appeal a decision to discharge a Medicare A patient from the hospital. Simply worded, Medicare beneficiaries have a right to medical care based on medical need - not Medicare payment.
If the hospital believes that the care ordered by the doctor may not qualify for Part A payment by Medicare as inpatient acute care, it may notify the beneficiary in writing that if he/she chooses to stay in the hospital, he/she will be financially responsible for the care provided. If the patient does not agree, they should contact the Peer Review Organization for assistance.
To appeal a Hospital Issued Notice of Non-Coverage, the beneficiary should be aware of the following:
- The hospital must provide written notice to the beneficiary. The notice, called a Hospital Issued Notice of Non-coverage, is not a decision by Medicare.
- An appeal may be requested by anyone involved--the beneficiary, a representative, or hospital personnel.
- The appeal must be initiated before the patient leaves the hospital.
- The Peer Review Organization cannot review the case until a Hospital Issued Notice of Non-coverage has been delivered. If the hospital does not issue a Hospital Issued Notice of Non-coverage, but says the beneficiary will be financially responsible or must leave the hospital, the beneficiary/representative should contact the Peer Review Organization for assistance.
- Request for an "immediate" review will give the beneficiary an answer within three days.
In general, a Medicare Part A beneficiary may want to appeal a Medicare decision when:
- Part A pays much less on a claim than he or she expected;
- Part A denies coverage for a service when coverage was expected by the beneficiary;
- Mistakes occurred; or
- New information is available.
The following chart summarizes the appeals process:
|Type of Action||Restrictions/Requirements|
|Time Limit:||60 days|
|Jurisdiction:||Intermediary or Peer Review Organization|
|Social Security Administration Form:||SSA 2649|
|2. Hearing, (Administrative Law Judge)|
|Time Limit:||60 days|
|Minimum Amount in Dispute:||$100 ($200 for Peer Review Organization)|
|Jurisdiction:||Bureau of Hearings and Appeals (BHA)|
|Social Security Administration Form:||HA 501.1|
|3. Appeals Council Review|
|Time Limit:||60 days|
|Minimum Amount in Dispute:||$100, ($200 for Peer Review Organization)|
|Jurisdiction:||Bureau of Hearings and Appeals (BHA)|
|Social Security Administration Form:||HA 520|
|4. Judicial Review, (Federal Court System)|
|Time Limit:||60 days|
|Minimum Amount in Dispute:||$1000, ($2000 for Peer Review Organization)|
|Jurisdiction:||U.S. District Court|
When Medicare payment is denied, the denial notice will tell you if you are liable for any of the denied amount.
If you have not received written notice prior to the delivery of service, you probably will be protected from payment. Do not automatically pay the provider when Medicare has denied payment. Find out who is responsible for the denied amount.
- When a Medicare claim is disallowed, the beneficiary may be responsible for paying the provider for services rendered. However, in many cases, the beneficiary may have received services without knowing Medicare would not pay for them and can request that they not be held responsible for the charges.
- Waiver of liability applies in situations where the beneficiary did not know, and could not have been expected to know, that services he or she received were not covered by Medicare.
- Facility, (hospital, nursing home, or home health agency), must be Medicare certified.
- Provider must have accepted assignment.
- Claim has been denied on grounds that:
- The service was not medically necessary
- The service was not delivered in the appropriate setting
- The service was not reasonable or necessary for diagnosis or treatment of illness or injury
- The service was for custodial care, (in a nursing home).
- If both the beneficiary and provider did not know, and could not have been expected to know, that expenses incurred were excluded from coverage, Medicare pays the provider under the waiver of liability provision.
- The denial notice you receive will tell you if you have been protected from having to make payment, (liability).
- If Medicare denies coverage for services, and you have already paid the provider, (and the provider knew or should have known that the service would be denied), the provider will reimburse you. If the provider will not reimburse you, contact Medicare Part A for assistance.