93.774: Medicare: Supplementary Medical Insurance

Popular Name: Medicare

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.



Applicant Eligibility: All persons age 65 and over, and those under age 65 who are eligible for hospital insurance benefits (see 93.773), may voluntarily enroll for supplementary medical insurance (SMI). The beneficiary pays a monthly premium. In calendar year 1996, the base premium is $42.50. Some States and other third-party buy-ins 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 or disability. This program is excluded from coverage under OMB Circular No. A-87.


Preapplication Coordination: None. This program is excluded from coverage under E.O. 12372.

Application Procedure: Phone 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, coverage may be declined. 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: An eligible individual who declines enrollment at first eligibility may enroll during any general enrollment period (the first 3 months of each year). The monthly premium amount is increased by 10 percent for each 12 months in which a person could have been, but was not enrolled. Certain individuals may also enroll during special enrollment periods based on coverage by an employer group health plan (EGHP): (1) individuals age 65 or older and employed, or the spouse of an employed person; or (2) individuals under age 65 and employed, or the family member of an employed person. If the coverage of individuals under age 65 and employed was not through a large group health plan (LGHP), that is, a plan of an employer of 100 or more employees or of a group of employers at least one of which had 100 or more employees, no family member other than the spouse qualifies for the special enrollment period. (The special enrollment period is the first 7 months after employment ends for the aged individuals, and the first 7 months after the EGHP stops being the primary payer for health care services for the disabled.) The premium surcharge may also be reduced for these individuals.

Range of Approval/Disapproval Time: Not applicable.

Appeals: Phone or visit the local Social Security Office or the Medicare payment organization responsible for the initial determination. The appeal process ranges from a review to a formal hearing. No judicial review is provided.

Renewals: Not applicable.

Criteria for Selecting Proposals: Not applicable.

Examples of Funded Projects: Not applicable.

Range & Average of Financial Assistance: The beneficiary is responsible for meeting an annual $100 deductible before benefits may begin. Thereafter, Medicare pays 80% of the fee schedule amount or the reasonable costs for covered services.


93.774 PROGRAM ACCOMPLISHMENTS: In fiscal year 1995, 5,498,000 persons were enrolled for supplementary medical insurance, and 2,778,000 had payments made on their behalf for covered services. In fiscal year 1996, the estimated number of enrollees increased to 36,006,000. In fiscal year 1997, the estimated number of enrollees will be 36,490,000.



Type of Assistance: Direct Payments for Specified Use.

Obligations: (Benefit Outlays) FY 95 $63,481,712,000; FY 96 est $69,055,000,000; and FY 97 est $76,287,000,000.

Budget Account Number: 20-8004-0-7-571.

Authorization: Social Security 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 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.

Regulations, Guidelines, & 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," (SSA) 79-10050, and other publications are available from any Social Security Office without charge.


Regional or Local Office: Consult Appendix IV of the Catalog for listing of Regional Offices.

Headquarters Office: Carol Walton, Director, Bureau of Program Operations, Health Care Financing Administration, Room 52-01-09, 7500 Security Blvd., Baltimore, MD 21244. Phone: (410) 786-8050. Use the same number for FTS.


Formula & Matching Requirements: This program has no statutory formula or matching requirements.

Length & Time Phasing of Assistance: Not applicable.

Uses & Use Restrictions: Benefits are paid on the basis of fee schedules or reasonable charges for covered services furnished by physicians and other suppliers of medical services to aged or disabled enrollees. Benefits are paid on the basis of reasonable costs for covered services furnished by participating providers such as hospitals and home health agencies.


Reports: None.

Audits: None.

Records: None.

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