1. What is Medicare?
A. Medicare is a federal medical insurance program that covers any citizen or legal resident 65 years or older. It is a joint program of the federal and state governments supported by the taxpayers, and it is available to those with little income and few assets. Medicare is a national health insurance program for people 65 years or older, younger people with certain disabilities, and people with permanent kidney failure who need dialysis (called End-Stage Renal Disease), or a transplant.
2. What does Medicare cover?
A. Part A-Hospital Insurance helps pay for necessary inpatient medical care in a hospital, skilled nursing facility, or psychiatric hospital, and for hospice and home health care. Part B-Medical Insurance helps pay for necessary physician services, outpatient hospital care, and other medical services and supplies not covered by Part A. Part C-Medicare Advantage (formerly known as Medicare+Choice) is available if you are entitled to Medicare Part A, enrolled in Part B, and provided you reside in the plan’s service area. Part D-Prescription Drug became available in January 2006.
3. Does Medicare pay any for any of the services provided in a nursing-care facility?
A. Medicare pays about 40% of the cost for home care services, paying less than 2 percent of all nursing-home costs. Medicare pays only for stays in skilled nursing facilities (facilities that provide 24-hour nursing care) that are Medicare-approved and only if admission directly follows a hospital stay of at least three days. Coverage is limited to 100 days per episode of illness.
4. What are the qualifications for Medicare payment for skilled nursing facility?
A. To qualify for Medicare payment for skilled nursing care in a skilled nursing facility:
1. The individual must have received inpatient hospital care for at least three days;
2. The individual must enter a skilled nursing facility for the same reason that required the hospital stay: and
3. The individual must enter that skilled nursing facility within 30 days of the hospital stay.
The longest skilled nursing home stay that Medicare will pay for completely is 20 days. After the first 20 days, if you still require skilled care, Medicare will pay only part of the nursing-home bill. You will have to pay a co-payment for each of the next 80 days. It must also be determined that you are getting better and that you will need skilled nursing care seven days a week and/or rehabilitative services at least five days a week for Medicare to continue to pay for nursing home care.
5. Will Medicare pay for any nursing home stays where you only need help with the activities of daily living?
A. No. Medicare will not pay for any nursing home stays where you only need help with the activities of daily living, such as eating, getting dressed, or going to the bathroom.
6. Will Medicare pay the cost of the nursing home?
A. Medicare will cover the cost of a nursing home stay only under certain circumstances.
The criteria are:
• The individual requires skilled care
• The care is provided only after a three or more day hospital stay for treatment of the same illness or condition that was treated in the hospital.
• The nursing home is a Medicare-approved skilled nursing home with a registered nurse on duty 24-hours a day
• The patient is assigned to a bed that is Medicare-certified for reimbursement.
• Only a nursing home can provide the skilled care required.
Even if these criteria are met Medicare only covers the cost of care for up to 20 days. An additional 80 days may be provided on a co-payment basis.
7. Are there any requirements that must be met before Medicare will pay approximately 40% for home care services?
A. Yes, if you need care in your home, Medicare may pay some of the expenses, but you must meet certain requirements:
• You must be homebound and require skilled-nursing or rehabilitative services.
• Services received must be from a home health-care agency that participates in Medicare.
8. Does Medicare pay for personal care services?
A. You may receive some personal care services along with the skilled services, but you will not be covered for general services to help you with your personal needs such as housecleaning or grocery shopping.
9. Are there specific qualifications to qualify for Medicare benefits for at-home café?
A. In order to qualify for Medicare benefits for at-home care an individual must:
• Be confined to home.
• Require skilled nursing care, physical therapy or speech therapy on an intermittent basis, or when those services are no longer needed, still require occupational therapy.
• Have a plan of care that is provided and periodically reviewed by a physician.
• Be under a physician’s care while receiving services.
10. What is Medigap Insurance?
A. Medigap Insurance is an insurance that was designed to supplement Medicare benefits.
11. Is Medigap sold as part of Medicare or Medicaid, or in addition to?
A. No. These policies are sold by private insurance companies and are regulated by federal and state law. The Medicare plan must be clearly identified as Medicare Supplemental Insurance and it must provide specific benefits that will help fill the gaps in your Medicare coverage.
12. Is there specific information I should have regarding Medigap Insurance before purchasing a policy?
A. There are 12 standardized Medigap plans called “A” through “L”. Each plan, “A” through “L” has a different set of benefits.
13. Can you give an example of some of the benefits of a specific Medigap plan?
A. Plan “A” covers only the basic (core) benefits. These basic benefits are included in all the plans, but Plan “K” and “L” also include hospice care.
14. Are there any restrictions with a Medigap Insurance Policy?
A. Medigap policies help pay health care costs only if you have the Original Medicare Plan. You don’t need to buy a Medigap policy if you are in a Medicare Advantage Plan. In fact, it is illegal for anyone to sell you a Medigap policy if they know you are in one of those plans.
15. Who is considered the most qualified to assist with obtaining Medicare benefits?
A. There are two important people who work in a hospital. The Medical Case Manager (MCM) and the Licensed Clinical Social Worker (LCSW).
16. What are the specific responsibilities of each?
A. The Medical Case Manager (MCM) is an experienced clinical nurse who, for her patients, interacts and advocates with insurance companies, physicians and possible placement facilities and agencies. The Licensed Clinical Social Worker (LCSW) works closely with the case manager. He or she is at the center of every crisis.
17. Is there a limit on the time that is covered by Medicare for skilled nursing home care?
A. The average time that individuals are covered by Medicare for skilled nursing home care is two weeks or less.
18. Do immediate family members qualify to receive direct payments for rendering caregiver services and/or treatment to an insured?
A. If the family member is, a certified employee of a care giving agency, a regular employee of an organization that is providing the services, the organization receives the payment for the services and the family member receives no compensation other than the normal compensation for employee in his/her job category.
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