Federal Medicare Regulations

Medicare is a federally-funded health insurance program for people 65 years of age and older, and for others who are eligible due to certain diseases or disabilities. It was first signed into law as part of the Social Security Act of 1965. Then-President Lyndon B. Johnson presented the first Medicare card to former President Harry S. Truman. Since then, the government expanded the program to include Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans) and Part D (comprehensive drug coverage). The Medicare law is also referred to as Title XVIII of the Social Security Act.

Eligibility

• Under federal regulations, only individuals who have been legal residents for at least five continuous years are eligible for this health insurance program. In addition, an individual (or his spouse) must have paid Medicare taxes for at least 10 years. In other words, the jobs must have been covered by social security. An individual who is not yet 65 years old can qualify for Medicare insurance if he is disabled and has been receiving Social Security Disability Insurance benefits for at least 24 months. You apply for enrollment in Medicare at the Social Security office. However, Medicare is administered by the Centers for Medicare & Medicaid Services (CMS).

Coverage

• There are multiple regulations regarding what Medicare does and does not cover. For instance, Medicare will not cover expenses for any procedures or devices that have been deemed "unnecessary" and "not reasonable" by the CMS. The Food and Drug Administration (FDA) categorizes all equipment as either experimental/investigatory or non-experimental/ non-investigatory. Medicare does not cover any treatment using experimental/investigatory devices.

Denial of Benefits

• If you receive a denial, reduction of benefits, or even complete termination of Medicare, you have the right to appeal the decision. You must file the appeal within 60 days of the date of the written notice. A Social Security Administrative Law Judge hears the case, and both sides present evidence and witnesses. If you are unsuccessful, you can appeal to the Social Security Appeals Council, although there is no hearing at this stage. Further appeals go to the U.S District Court, but this is just to ensure that there were no errors of law in the judgment. There is no hearing.