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Medicare Answers

If in the future, you find you or a loved one are in need of skilled services, you may wish to make the Medicare program an important part of your insurance coverage. Since Medicare is a complicated program governed by numerous rules and regulations, many of which change from time to time, I will try to explain some of the more frequent misunderstood aspects of the program, as well as the benefits of Medicare. I want to help you take the guess work out of Medicare.

What is Medicare?

For anyone 65 or older; people of any age with permanent kidney failure; or those receiving Social Security disability benefits, Medicare is a federal insurance program providing two types of coverage:

  1. Hospital Insurance - Part A helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, and certain home health care services.
  2. Medical Insurance - Part B helps pay for your doctor's services and other medical services and supplies not covered by Medicare hospital insurance - Part A.

Medicare Benefits Can Help You to Live and Recover at a Skilled Facility if…

  • You have been a hospital patient for 3 consecutive days, not counting the day of discharge.
  • You are admitted to the skilled nursing facility within 30 days of your hospital discharge.
  • The services you require are related to the condition for which you were treated in the hospital.
  • You require skilled nursing services or rehabilitation services on a daily basis.
  • These services, as a practical matter, can only be provided on an inpatient basis.
  • Your doctor orders and certifies at time of admission that you need skilled care services on a daily basis, and again, certifies your need 14 days after admission and every 30 days thereafter.
  • A Utilization Review Committee of professionals regularly reviews and approves your continued need for skilled care services.
  • Your stay in the skilled nursing facility is 100 days or less.

You May Receive Help From Medicare on all These Services:

  • a semi-private room
  • all meals, including special diets
  • nursing care
  • rehabilitative therapies
  • drugs prescribed by a physician
  • medical supplies
  • use of appliances and equipment

What Kinds of Illnesses or Disabilities Does Medicare Ordinarily Cover in a Skilled Care Facility?

Many different illnesses or disabilities can be covered by Medicare hospital insurance - Part A. Your eligibility for coverage depends on your need for skilled care services on a daily basis. A skilled care service is defined as a service that is provided on a daily basis directly by or requiring the supervision of a licensed nurse or registered therapist. The following services are considered the most common skilled care services: decubitus care; Levine tube; intravenous therapy; sterile dressings; tracheostomy care (if surgery is recent); daily multiple injections; physical, speech and occupational therapy which must be required on a daily basis. The facility's staff should be glad to assist you in determining whether an illness or disability qualifies for Medicare coverage.

How Many Days of Service Will Medicare Hospital Insurance - Part A, Help Pay For When I am in a Skilled Nursing Facility?

Medicare hospital Insurance -Part A helps pay for up to 100 days in a participating skilled nursing facility in each benefit period. The 100 days of coverage are not automatic since continued eligibility for coverage remains in effect only as long as the preceding conditions are met and skilled care services are required on a daily basis. The foregoing information explains the maximum coverage under Medicare hospital insurance -Part A. However, actual experience shows that patients receive an average of about 24 days of covered care.


Medicare Summary as of January 1, 2014

HOSPITAL INSURANCE - PART A

Service: Skilled Nursing Facilities Certified By Medicare (Inpatient)

First 20 Days: You Pay Nothing, Medicare Pays 100%

Next 80 Days: You Pay $152 a day, Medicare Pays balance of covered charges

Requirements:

Admission to a skilled nursing facility must occur within 30 days of a hospital confinement of 3 or more days; must be an extension of the hospital treatment; and must be for daily skilled nursing and/or therapy services which as a practical matter can only be provided on an inpatient basis.

Not Covered:

Private duty nurses, first three pints of blood, personal convenience items such as barber, beautician, personal laundry, private telephone and television.
MEDICAL INSURANCE - PART B

Service: Skilled Nursing Facilities, Certified By Medicare (Outpatient)

Doctor's visits; physical, occupational, and speech therapy; lab and X-ray services; prosthetic devices and some supplies and equipment.

Unlimited Time Limit: You Pay one annual deductible of $100 plus 20% of the balance of reasonable charges, Medicare Pays balance of reasonable charges.

*Beneficiaries of Medicare Insurance - Part B must satisfy only one $100 deductible. All products or services covered by Part B count toward that deductible.

Requirements:

Not eligible for Medicare Part A (Hospital Insurance) benefits.

Not Covered:

Most central supplies, personal items, and room and board.


For further information on Medicare Parts A, B or D (Pharmacy), please go to Medicare.gov

**If you are a nursing home patient or family member you can also contact the administrator of your nearest nursing home facility for more detailed information about your Medicare benefits.

**This information pertains only to the fee-for-service (traditional) Medicare program. The above information does not apply to the additional Medicare options that are now available, such as Medicare HMO programs and Medicare replacement policies.