What is Medicare?


Medicare is one of the most misunderstood government programs in identifying what is actually covered for long-term care services. Medicare is a federal program administered by the Center For Medicare and Medicaid. It is available to people at age 65 or those with end stage renal disease.

There are two parts to Medicare. Medicare PART A covers hospitalizations, skilled nursing care, home health care and hospice. There is no charge for Medicare Part A benefits unless you have not had more than 39 quarters of Social Security coverage. If you have had less than 39 quarters you can purchase Medicare Part A.
Medicare PART B covers doctor and medical services, equipment, therapies, lab tests and x-rays. Part B costs $54.00 per month and is an optional benefit.

HMO's

HMO's are required by law to offer the same benefits that Medicare offers. To encourage people to assign their Medicare benefits to an HMO, many HMO's offer additional ancillary benefits like vision and prescription benefits.

Medicare and HMO's are designed to pay for acute medical care needs. They pay for short term, rehabilitative care. This type of care is provided by licensed professionals. It is also called skilled care. Skilled care is determined by the types of services a person receives. An example would be physical therapy after a stroke, or IV therapy.

Medicare pays for care in skilled nursing facilities, and for home health care. Medicare does not pay for long-term care. Long-term care is when people need assistance with activities of daily living or supervision due to a cognitive impairment. Medicare was not designed to cover chronic conditions.

Medicare Skilled Nursing Facility Benefits

To be eligible for Medicare benefits in a skilled nursing home facility, the patient must meet the following requirements:

  • 3 day hospital stay (not including the day of discharge)
  • Care needed must be skilled nursing or skilled rehabilitation services
  • Skilled Nursing Facility must be certified by Medicare.
  • Physician must certify the need for this skilled care on a daily basis

If the patient qualifies for all of these criteria, they can qualify for UP TO 100 days of Medicare benefits. Medicare will pay for the first 20 days at 100%. Days 21-100 Medicare will pay for everything except a co-pay of $101.50 per day. If the patient has a Medicare Supplement or an HMO this charge may be covered as well.

The average Medicare stay in 1999 was only 23 days. It is very rare for someone to get the full 100 days of coverage. When skilled care is no longer needed, the care usually becomes custodial care. Medicare does not pay for custodial care in a nursing home.

Medicare Home Care Benefits

Medicare will only pay for care in the home if there are skilled services needed. The care needed can only be part time or intermittent home health care. Medicare will NOT pay for care longer than a regular visit to perform services. As an example, Medicare would not pay for a home care aid to stay for 8 hours or a 24 hour shift. The requirements are as follows:

Medicare defines intermittent care as skilled nursing care that is provided on fewer than seven days each week, or less than eight hours each day (combined) for 21 days or less.

The patient must be home-bound. This is defined as a medical condition restricting the ability to leave the house except with assistance- or if it is medically inadvisable to leave the house.

The patient must be under a physician's care and the physician must certify the need for the home health care.

The home health care agency providing the services must be certified by Medicare.

Unlike Medicare SNF benefits, there are no co-payments for home care services paid under Medicare.

Medicare Supplements

When Medicare was implemented it was determined that there should be balances to the care that people received. This causes people to use Medicare benefits wisely.
There are 10 standard Medicare Supplement policies on the market. They are also known as "Medigap" coverage. These policies pay the co-insurance amounts that Medicare does not pay. For example on days 21-100 that Medicare pays everything except the $101.50 - a Medicare Supplement policy could pay that. (Medicare Supplement plans A and B do not cover this co-payment for skilled nursing facilities)

If Medicare is not paying for care or services, then the Medicare Supplements will not pay either. There are a few exceptions to this.

If you have questions about the Medicare program you can call the Social Security Administration at 800-772-1213. They can answer questions about eligibility.

This is a summary of how Medicare, HMO's, and Medicare Supplements work.
 
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