Understanding Medicare

What Does Medicare Cover?

Medicare does not provide a comprehensive long-term care component and generally does not cover assisted living residence or personal care home costs but may pay for short-term services (e.g. physical and other therapies) contracted through a home health care agency and provided to the resident at the assisted living residence or personal care home. Medicare covers only those skilled nursing facility services rendered to help someone recover from an acute illness or injury. Medicare is administered by the federal government’s Centers for Medicare and Medicaid Services (CMS) and is divided into two parts: Hospital Insurance (Part A) and Medical Insurance (Part B).

Eligibility:

Skilled nursing facility coverage falls under Part A of Medicare and is very limited. If certain conditions are met, Medicare only pays fully for the first 20 days of care in a skilled nursing facility.

For the 21st through the 100th day, the patient must share, or co-pay, for the cost of care by paying a daily coinsurance rate, which changes yearly. (This is typically what a Medigap policy covers.)

Medicare Pays for Skilled Nursing Facility Care Only Under the Following Conditions:

  1. The skilled nursing facility provides 24-hour nursing care to patients.
  2. Continuous skilled nursing care or skilled rehabilitation services (as defined by the federal government) are required on a daily basis.
  3. The patient has spent at least three consecutive inpatient days (not under observation) in a hospital and if the admission to the skilled nursing facility occurs within 30 days after discharge from the hospital.
  4. A physician certifies that skilled nursing facility services are needed for the same or related illness for which the person was hospitalized.

Coverage:

Services Covered by Medicare:

  • A semi-private room
  • Meals, including special diets
  • Regular nursing services
  • Rehabilitation services
  • Drugs furnished by the facility
  • Medical supplies

Services Not Covered by Medicare:

  • Personal convenience items
  • Private duty nurses
  • Extra charges for a private room

Medicare Part B may help pay for covered services you receive from your doctor in a skilled nursing facility, if you choose to participate in the Part B medical insurance program. If you have used up your Part A coverage for a spell of illness, Part B also covers a portion of services received in a skilled nursing facility, such as physical and occupational therapy. Under the Part B program, you must pay an annual premium and a deductible for all Part B services, including physician services, after which Medicare pays 80 percent of the reasonable charges for covered services.

Services Not Included Under Medicare Part B:

  • Routine foot care
  • Eye or hearing exams for prescribing or fitting eyeglasses or hearing aids
  • Immunizations other than for the flu or pneumonia

How to Apply for Medicare:

Contact your nearest Social Security office to find out if you are automatically covered for Part A because of credits for the number of (calendar) quarters worked in your lifetime. Also, if you are interested in signing up for Medicare medical insurance (Part B), the Social Security office can assist you with that process. Keep in mind, though, that you can only sign up for the insurance in the first three month of the calendar year or upon reaching age 65.

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