WHAT IS MEDICARE?
Medicare is the federal government’s single largest health insurance program, covering
nearly 40 million Americans and growing. This health insurance program is for people 65 years of age and people with End-Stage Renal disease (permanent kidney failure treated with dialysis or a transplant). The Centers for Medicare and Medicaid Services (CMS) administer the Medicare program.
WHO IS ELIGIBLE FOR MEDICARE?
Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States.
Here are some simple guidelines. If you are age 65 or older, you are eligible for Medicare Part A benefits without having to pay premiums if:
- You are already receiving retirement benefits from Social Security or the
Railroad Retirement Board.
- You are eligible to receive Social Security or Railroad benefits but have not yet filed
- You or your spouse had Medicare-covered government employment.
If you are under 65, you can receive Medicare Part A benefits without having to pay premiums if:
- You have received Social Security or Railroad Retirement Board Disability benefits for 24 months.
- You are a kidney dialysis or kidney transplant patient.
- Medicare Part B is a voluntary program for which participants pay a monthly premium. The cost of the premium is deducted from your Social Security, Railroad Retirement or Civil Service retirement check. If you do not receive any of the above payments, Medicare sends you a quarterly bill for your Part B premium. Remember that enrolling in Medicare Part B is your choice.
WHAT ARE THE Two PARTS OF MEDICARE?
Medicare Part A (also known as hospital insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (SNF). It also covers hospice care and some home health care for persons who meet certain conditions.
Medicare Part B (also known as medical insurance) helps cover your doctor’s services, outpatient hospital care and some other medically necessary services not covered by Medicare Part A, such as some services of physical and occupational therapists and some home health care.
WILL MEDICARE COVER SKILLED NURSING CARE?
Medicare Part A will cover skilled nursing care only if all of the following conditions are met:
1. You have Medicare Part A coverage and you have days left in your benefit period.
2. You have a qualifying hospital stay. This means an inpatient stay of three consecutive
days or more, not including the day you leave the hospital.
3. You are admitted to the SNF within 30 days of leaving the hospital.
4. Your doctor has decided that you need skilled care. Skilled care requires the involvement of skilled nursing or rehabilitation staff to be given safely and effectively. Skilled staff includes:
- Registered nurses;
- Licensed practical and vocational nurses;
- Physical and occupational therapists;
- Speech-language pathologists; and
5. You receive these services in a SNF that has
been certified by Medicare.
How LONG DOES MEDICARE PART A COVER MY SKILLED CARE?
Medicare uses a period of time called a benefit period to keep track of how many days of skilled nursing benefits you use, and how many days are still available. A benefit period begins on the day you start using hospital or SNF benefits under Part A of Medicare. If you use skilled level of care days at the hospital, these will be included in the 100-day benefit period. You can receive up to 100 days of skilled care in a benefit period. However, it is important to note that benefits under Medicare Part A may end sooner than the 100th day if you no longer need skilled care.
Medicare Part A pays 100% of the first 20 days of approved covered services. You (or another payment source such as Medicaid, Medigap, long-term care insurance, etc.) are liable for a daily co-insurance payment for the next 80 days.
You may inquire in the business office about the current coinsurance rate. For more information about help paying for health care, you may call the State Health Insurance
WHAT DOES MEDICARE COVER WHEN I QUALIFY FOR SNF CARE?
If your doctor determined that you need daily skilled care, Medicare Part A will pay for these services in a Skilled Nursing Facility (SNF). Services will be covered for as long as
medically necessary, up to a maximum of 100 days:
- A semi private room
- Daily skilled nursing care
- Physical therapy *
- Occupational therapy*
- Speech-language therapy*
- Medical social services
- Medical supplies and equipment used in the SNF
- Dietary/Nutrition counseling
- Laboratory tests, diagnostic x-rays, MRIs, CT scans, EKGs
- Blood transfusion
- Enteral/Parenteral Supplies, TPN Supplies
- Orthotic and prosthetic devices
- Ambulance transportation (if meeting Medicare criteria and on Care Plan)
* Therapies are covered jf they meet your health goal(s). To qualjfy as “skilled”
services under Medicare ParUA, thearpists must be provided to you a minimum offive days each week.
WHAT IS COVERED BY MEDICARE PART B?
Medicare Part B (Medical Insurance) helps cover your doctor’s services, outpatient hospital care and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. If you have chosen to enroll in Medicare Part B, it may help cover your:
- Medical and other services (not routine physical exams)
- Outpatient services and supplies
- Laboratory tests, diagnostic x-rays, MRIs, CT scans, and EKGs
- Blood transfusion
- Ambulatory surgery center fees for approved procedures
- Durable medical equipment (such as wheelchairs, walkers, oxygen)
- Therapies (PT, OT, Speech) when not covered by Medicare Part A
- Enteral nutrition (when this is the only source of nutrition received)
- Orthotic and prosthetic devices
- Telemedicine in some rural areas
- Ambulance transportation (if medically necessary)
A more detailed list of services covered under Medicare is available from the
Center for Medicare and Medicaid, or by visiting the “Your Medicare Coverage”
section of the Medicare Web site. The address is www.medicare.gov.
How DOES MEDICARE PAY MY BILL?
When you are admitted to a Skilled Nursing Facility, you will be asked to provide a copy
of your Medicare card. Once the Business Office has a copy of your card on file, the staff
will then bill Medicare for your care. All claims are handled by insurance organizations
called intermediaries, which then issue payment to the SNF.
How WILL I KNOW WHEN MEDICARE Is COVERING MY COSTS?
Your eligibility will be determined by your physician and the Medicare team. If you are not eligible to receive Medicare benefits under Part A, the facility will issue a denial letter explaining why you are not eligible (i.e., upon admission, post-hospitalization or when Medicare benefits are exhausted). You will be informed what, if any, services are billable
under Medicare Part B. Upon receipt of a denial letter, you may request that your services be billed to Medicare, even though the charges may not be covered. If the charges are not covered, you will be responsible for payment.