Medicare and Medicaid do not pay for an unlimited amount of long-term care. How these various government-sponsored insurance programs work can be confusing.
Medicare is an insurance program backed by the US government for those over 65 years of age, as well as people with specific disabilities or kidney disease. For medical treatment to be covered under Medicare, it must meet certain standards, including approval by a medical professional. Treatment must be provided by a Medicare-certified partner, like Senior Care Centers, to be covered.
Medicare Part A:
- Part A pays all or part of the costs for 90-day inpatient hospital stays. Patient pays deductible upon admission to hospital and co-pay on days 61 through 90
- For skilled nursing facility treatment to be covered, a patient must have had a hospital stay of minimum 3 nights and been transferred to a skilled nursing facility with 30 days of being discharged.
- Part A covers qualifying skilled nursing treatment for up to 100 days per benefit period, with the first 20 being paid in full by Medicare and the last 80 requiring a co-pay. For benefits to regenerate, you must not be receiving skilled nursing treatment, in our out of a facility, for at least 60 consecutive days.
- If a patient opts for hospice care in a qualifying Medicare program, Part A covers most of the cost.
Medicare Part B:
- Requires $124 deductible per year, along with 20 percent of all Medicare approved charges beyond that. Part B pays the other 80 percent relating to:
- Unless you intentionally opt out, enrollment in Part B is automatic when you enroll in Part A. Premiums are required for coverage under Part B.
- Medical and surgical procedures the patient receives in a physician’s office, a hospital, a skilled nursing facility, or at home;
- Diagnostic tests and procedures related to treatment;
- The medical opinion of a second physician when appropriate;
- Services received in an emergency room or outpatient clinic;
- Mental health care in a hospital outpatient setting;
- Medically necessary ambulance transportation;
- Qualified Durable Medical Equipment (e.g., oxygen equipment and wheelchairs);
- Outpatient physical, occupational and speech therapy;
- Other designated services.
Medicare Part D:
Part D covers prescription medications for those enrolled in Part A or B, with standard and low income plans for those on fixed incomes. Enrollment is not automatic like with Part B – you must intentionnaly enroll in Part D if you want coverage. A co-pay, monthly premium, and yearly deductible are required.
Medicaid is a state-administered program – meaning it can differ from state to state – that pays for skilled nursing coverage pending you meet certain eligibility requirements set by the federal government. These include, but are not limited to:
- Patient must be at least 21 year old
- Patient must be US citizen or resident alien.
- Patient must have a medical need for nursing facility services, as noted by a qualified medical professional
- Patient’s monthly income and countable assets must not exceed the eligibility limits set by the state
As long as one meets the eligibility requirements, they continue to receive coverage.