Will
Medicare Help Pay Long-Term Care Costs?
What
is Medicare?
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.
The
Two Parts to Medicare:
PART A covers hospitalizations, skilled nursing care,
home health care and hospice. There is no charge for Medicare
Part A benefits for those who have 39 or more quarters of
Social Security coverage. Those with less than 39 quarters
can buy Part A coverage.
PART B covers doctor
and medical services, equipment, therapies, lab tests and
x-rays. Part B is an optional benefit and has a monthly
cost that is determined each year by Social Security.
HMO's
HMO's are required by law to offer the same benefits that
Medicare offers. Many HMO's offer additional ancillary benefits
like vision and prescription benefits so people will sign
over their Medicare benefits.
What
is Skilled Care?
This coverage is designed to pay for acute medical care
needs and short term, rehabilitative care. This type of
care (called skilled care) is provided by licensed professionals.
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 set up to cover chronic conditions.
Medicare
Skilled Nursing Facility Benefits
To be eligible for
Medicare benefits in a skilled nursing home facility, the
applicant 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 applicant meets
all of these criteria, they can qualify for UP TO 100 days
of Medicare benefits. Days 1-20 Medicare will pay at 100%.
Days 21-100 Medicare requires a co-pay from the insured.
Medicare Supplement or HMO policies may cover this.
In 1999, the average Medicare
stay was only 23 days. A full 100 days of skilled care is
rarely needed. When skilled care is no longer needed,
the care becomes custodial care. Custodial care is not
covered by Medicare.
Medicare
Home Care Benefits
Medicare will only
pay when skilled services needed. Only part time or intermittent
home health care is covered. Medicare pays ONLY for regular
service visits, NOT for custodial care. Home care aid services
are defined as custodial care. Qualified benefits 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.
No co-payments are required
for home care services paid under Medicare.
Medicare
Supplements
Medicare doesn't cover
everything, so there are policies that try to fill some
of the gaps.
Ten standard types of
Medicare Supplement (Medigap) policies are available. The
coverage they offer is paying the co-insurance amounts listed
above.
Be aware that these supplements
only cover Medicare qualifying expenses. If Medicare is
not paying, then Medicare Supplements won't, with few exceptions,
pay either.
Call the Social Security
Administration at 800-772-1213 if you have questions about
Medicare. They can answer questions about eligibility.
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