Scanning sources…acquiring signal · establishing uplink
66M+
enrolled in Medicare (2025)
$1.0T
projected 2026 program spend
54%
of beneficiaries in Medicare Advantage
800+
stand-alone PDP + MA-PD plans
Program Structure
Four interlocking benefit categoriesHospital Insurance
Inpatient hospital stays (60-day benefit period, deductible $1,676 in 2025)
Skilled nursing facility (SNF) care up to 100 days post qualifying stay
Home health care (medically necessary)
Hospice care for terminal illness
Most beneficiaries pay $0 premium (40 quarters of work history)
Medical Insurance
Physician and outpatient services; standard premium $185.00/mo (2025)
Durable medical equipment (DME) and preventive services
Mental health, lab tests, X-rays, home health
20% coinsurance after $257 annual deductible
Income-related monthly adjustment amount (IRMAA) applies above $106K AGI
Medicare Advantage
Private plan alternative covering Part A + B benefits (must match or exceed)
Often includes Part D, dental, vision, hearing extras
CMS-4201-F (2024): parity with FFS on coverage criteria and PA restrictions
AI-based denial tools constrained — individualized review required
Star ratings (1–5) drive quality bonus payments and plan retention
Prescription Drug Coverage
Stand-alone PDP or integrated MA-PD plans offered by private insurers
Formulary tiers: generics → preferred brand → non-preferred → specialty
IRA 2022: $2,000 out-of-pocket cap effective 2025; manufacturer rebate restructure
Low Income Subsidy (LIS / Extra Help) covers premium + cost-sharing for qualifying beneficiaries
CMS Formulary Reference Files published annually with NDC-HCPCS crosswalk
FFS vs Medicare Advantage Enrollment (millions)
Spending by Part (%)
FFS vs Medicare Advantage
Key structural differencesCMS Internet-Only Manual (IOM) System
Key publications governing Medicare operationsGeneral Info, Eligibility & Entitlement
Medicare Benefit Policy Manual
National Coverage Determinations (NCD)
Claims Processing Manual
Medicare Managed Care Manual
Prescription Drug Benefit Manual
Program Integrity Manual
Public Data APIs & Machine-Readable Sources
CMS developer ecosystemBlue Button 2.0
FHIR API for beneficiary claims data — Part A/B/D. OAuth 2.0 + PKCE. 13-month token for ongoing apps.
Procedure Price Lookup
Public API for procedure pricing by ZIP/specialty. API-key registration required.
Data.Medicare.gov
Care Compare machine-readable data: hospitals, physicians, nursing homes, HHAs, hospice.
Data.CMS.gov
Physician/supplier PUFs, Part D prescriber data, provider enrollment, market saturation files.
Marketplace API
ACA plan benefits, rates, formulary, doctor/drug coverage. Last 3 years of data retained.
Regulatory Timeline
Key legislative and regulatory milestonesCreated Part D prescription drug benefit and Medicare Advantage restructure
Established IPAB, reduced MA overpayments, expanded preventive coverage with $0 cost-sharing
Replaced SGR formula; created MIPS and APM pathways for quality-linked payment
CMS drug price negotiation authority; $2,000 Part D OOP cap effective 2025; rebate restructure
MA parity rule: 2-Midnight Rule applies to MA; AI-based denials must have individualized review
PA interoperability: electronic PA timelines, FHIR APIs required by 2026-2027
AI-assisted prospective review in 6 states for Medicare FFS; human final decision required
Medicare Knowledge Base
Environment 12 — ingested Medicare research, entities, and relationships