Medical Overview

The Medicare Law was passed in 1965. It is Title XVIII of the Social Security Act, called “Health Insurance for the Aged and Disabled. It is a health insurance program.

1. Persons 65 years or older who have made contributions through payroll deductions to the Social Security System.

2. Persons, under 65 years of age who have received state disability benefit for two years.

3. Persons, under 65 years of age who have been diagnosed with Chronic Renal Disease (End Stage Renal Disease) for three months.

Medicare pays for the following primary services:
• Skilled Nursing Care
• Physical Therapy
• Speech Therapy

If at least one of the above services is needed, then Medicare will also pay for:

• Occupational Therapy
• Medical Social Services
• Home Health Aide Services
• Medical Supplies and Equipment

The patient must be homebound.
The care must be intermittent.
The care must be reasonable and necessary.
The patient must be receiving “Skilled” nursing, or therapy services.
The patient must have restorative potential.

All of the above requirements must be met simultaneously. A patient’s claim can and will be denied if even one of the above criteria is not met.

Medicare has two components: PART A and PART B.

Medicare PART A: is financed by mandatory payroll contributions made during the time that a person is employed under social security benefits (FICA).

Medicare PART B: is financed through deductions from the person’s social security payment. It is a voluntary enrollment.

If the patient requires outpatient Physical or Speech Therapy, Medicare PART B will pay for 80% of the charges; the patient is responsible for the next 20%.

Medicare PART B is voluntary once the client has met PART A requirements.

1. The beneficiary pays monthly premiums - usually deducted from social security income.

2. The beneficiary has a deductible every year.

3. The State pays PART B premiums for patients who have (welfare) hospital benefits from Medi-Cal.

The alphabet following the social security number has certain implications.

A. This means that this member is a retired worker, over 65 years of age, or that this person is under 65 but is disabled.

B. Means this member is wife (over 65 years of retired or disabled worker).

C. Means Child (including disabled child or student).

D. Widower

E. Widowed mother

WA. Railroad Worker

Eligibility is strictly by financial need. To qualify, clients must show a certain limited amount of disposable income. They can own a home and their own transportation vehicle.

The coverage issues for clients receiving care under Medical reimbursement are entirely different from Medicare. Visits are limited. The delivery of care under a plan of treatment and the quality of care is the same for all patients.