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calendar quarter following the calendar quarter in which Termination for non-payment of

such notice is filed.

premiums will take effect with the end of the "grace period"36 during which overdue premiums may be paid and coverage continued.

In the case of an individual entitled to Hospital Insurance benefits and consequently Supplementary Medical Insurance benefits, on the basis of disability, coverage ends with the close of the last month for which he is

entitled to Hospital Insurance benefits.37

b. The Medicare Amendments of 1974

The Medicare Amendments of 1974 would greatly simplify the confusing network of eligibility and coverage requirements of present law. Under these Amendments, every individual who, at the time any service covered under Title XVIII is furnished to him, has attained the age of 65 and is a citizen or national of the United States, or is an alien lawfully admitted for permanent residence and is living in the United States, or is an alien and has been on a continuing basis, for a period of not less than 30 days immediately proceeding the furnishing of that service, lawfully present in the United States, or is an alien entitled to social security section 202 benefits or qualified as a railroad retirement beneficiary would

36Soc. Sec. Act 881838 (b) (2). 37 Soc. Sec. Act §§1838 (c).

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3.

be entitled to Health Insurance benefits with respect to

that service.38 The provisions of current law with respect

to entitlement and duration of coverage of disabled individuals are retained. 39

With respect to an individual who is under age 65 and who is medically determined to have chronic renal disease requiring renal dialysis or kidney transplantation, such an individual would be entitled to Health Insurance benefits provided that he is entitled to monthly cash benefits under Title II of the Social Security Act or to an annuity under the Railroad Retirement Act of 1937 or is a fully or currently insured individual or is the spouse or dependent child of such a person.

Coverage would begin

with the third month after the month in which eligibility requirements are met and a course of renal dialysis is initiated and would end with the twelfth month after the month in which the individual receives a kidney transplant

or in which the course of renal dialysis terminated.

Health Care Benefits and Durational Limitations

a. Present Law

The benefits provided to an individual by the Hospital Insurance program of present law consist of entitlement to have payment made on his behalf for inpatient hospital 38 Medicare Amendments of 1974 §§111 (b) (amending Title II of the Social Security Act). 39Also retained, but in modified form, is the provision pursuant to which an individual is deemed entitled to social security 202 or 223 (disability) benefits or is deemed a qualified railroad retirement beneficiary for the month in which he dies, if he would have otherwise been so entitled.

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services (including psychiatric and tuberculosis hospitals), post-hospital extended care services provided by a skilled nursing facility and post-hospital home health services." These services are limited in duration, however, in accor

40

dance with the beginning or ending of a "spell of illness."41
Inpatient hospital services 42
are covered for up to

43

90 days per spell of illness 44

In addition, each bene

ficiary has a lifetime reserve of 60 days of additional

coverage after exhaustion of the 90-day period. Post

45

hospital extended care services" furnished by a skilled
nursing facility are covered for only 100 days during a
46
spell of illness. Post hospital health services are
covered for up to 100 visits provided during a one-year
period beginning after the commencement of a spell of
illness and ending before the commencement of the next

spell. Finally, services provided by a qualified Christian

40 Soc. Sec. Act §§1812 (a).

41Under Soc. Sec. Act 1861 (a), a "spell of illness" is a period of consecutive days that begins with the first day (not included in a previous spell of illness) on which an entitled patient is furnished inpatient hospital or extended care services by a qualified provider. (Admission to a qualified skilled nursing facility will begin a spell of illness even though payment for the services cannot be made because the prior hospitalization or transfer requirement has not been met.) The "spell of illness" ends with the close of a period of 60 consecutive days in which the patient is neither an inpatient of a hospital or skilled nursing facility regardless of whether such a hospital or facility is a qualified provider.

42Defined in Soc. Sec. Act §§1861 (b).

43Soc. Sec. Act 681812 (a).

44Under Soc. Sec. Act §§1812 (b) (3) and (c), there are further limitations with respect to inpatient hospital services of a psychiatric hospital including a lifetime limit of 190 days for such services.

46

Defined in Soc. Sec. Act §§1861 (h), (i).

Defined in Soc. Sec. Act §§1861 (m), (n).

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Science Sanitorium are covered for up to 180 days in the same spell of illness up to 150 days of hospital ser

vices, and up to 30 days of extended care services.

Supplementary Medical Insurance, as a separate program, has its own package of covered services which builds upon, reinforces, and to some extent, duplicates Hospital Insurance benefits. The benefits provided to an enrolled individual consist of entitlement to have payment made to him or on his behalf for "medical and other health services"47 (including physician's services) and entitlement to have payment made on his behalf for home health services for up to 100 visits per year (no prior hospital stay requirement), "medical and other health services" furnished by a provider of services (hospital, skilled nursing facility or home health agency), excluding, however, most physician's services and outpatient physical therapy services.48

b. The Medicare Amendments of 1974

Health care protection would be far more comprehensive under the Medicare Amendments of 1974. New services would be covered and limitations on services already covered would be reduced or eliminated.

Under the Medicare amendments of 1974, entitlement of

an individual to benefits would consist of the right to

47 Defined in Soc. Sec. Act $81861 (s).

48 Soc. Sec. Act §§1832 (a).

33

have payment made on his behalf or to him when so speci-
fied, for covered institutional services49 including in-
patient and outpatient hospital services and including
such services in a psychiatric or tuberculosis hospital
or other specialized hospital, skilled nursing facility
services, intermediate care facility services (furnished
after June 30, 1978), home health services, health and
health-related services and items for the rehabilitation

of handicapped individuals, inpatient services of a Chris-
tian Science sanitorium, and health, health-related ser-
vices and items that are furnished to an individual by
an institution that is a public health agency or non-
profit private health agency or furnished by others
under arrangements.

50

Covered non-institutional services for purposes of
the Medicare Amendments of 1974 include the following:
professional services of a physician51 (when not covered
as institutional services), services, materials, and
supplies (including drugs), furnished as an incident to
a physician's professional services and commonly

49 Under Medicare Amendments of 1974, §§111(a)("1813(b)"), the term
"institutional services," includes all services that are fur-
nished or held out as available generally to patients or classes
of patients of the institution involved and are furnished by
the institution or by others under arrangements made
by the institution, including pathology and radiology services,
and all other professional and non-professional services so
furnished or held out as available, except that the term does
not include medical, surgical, or dental services by an inde-
pendent physician or dentist, or podiatry services by an inde-
pendent podiatrist furnished to an individual as the practitioner's
private patient.

50

51

Medicare Amendments of 1974, §§111 (a) ("1813").

Medicare Amendments of 1974, §§111 (a) ("1814").