When Does Medicare Pay For Nursing Home Care?

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One of the most common phone calls I receive in the office is when someone's mother or father is admitted to the hospital. In this time of crisis, answers are not easy to come by.

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How is When Does Medicare Pay For Nursing Home Care?

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How does their health insurance work? What does Medicare pay for? Once the parent is discharged, what happens, where do they go, how is it paid for, what are our options? What do we do if mom or dad is going to have to go to a nursing home? How do we pay for it?

This confusion is expected as the senior health care system can be a very confusing and overwhelming process. The first thing to do is to understand the basis for today's system.

In 1983, Congress created the Prospective Payment System. This is important because when a person 65 or older is admitted to a hospital, he is assigned only one of 473 Diagnostic Related Groups (DRG's). This is important because Medicare compensates the hospital a flat dollar amount for the DRG assigned to the patient.

Let me give you an example. Say that my father is admitted to the hospital with lung problems and the DRG is four days. If my father is discharged in three days, then the hospital makes one day of profit. If my father is discharged in five days then the hospital loses money and cannot bill the patient for the one extra day.

Back in the good old days, I remember when my grandfather was in the hospital and the nurse asked him if he felt well enough to go home because if he didn't, he could stay a few extra days until he felt better.

Today, it is all about the money. Once a patient is no longer getting better or worse, in other words, is deemed to be "stable", then the patient is discharged either to home or a Medicare certified nursing home or rehab facility.

In order for Medicare to pay for rehab care the patient must have been in the hospital for three consecutive days (72 hours). Then, no later than thirty days after discharge from the hospital, be admitted to a Medicare certified nursing facility.

If these criteria are met, then for 2010, day's one through twenty in the rehab facility are paid for 100% by Medicare. For days twenty one through one hundred, your co pay is for this year is 7.00 per day.

From day 101 and beyond, regardless of your condition, you are responsible for all of the facility costs.

Keep in mind, that in order for this reimbursement schedule to happen, you must either be getting better or getting worse. Like the hospital, once you are deemed to be stable, you come off the Medicare reimbursement schedule and must pay for all costs.

In California, most patients will come off of Medicare reimbursement around week three and must begin private paying from this point forward. The business office will advise you when this is expected to take place.

If the facility has long-term care beds, then the patient may be able to stay in the same facility. But if the facility is strictly short-term care or rehab, then the patient must find another facility or go home.

How does the patient's health insurance fit into this? It all depends on what type of plan that the senior patient is on. Is it a Medicare supplement plan or PPO, or is it a Medicare Advantage plan like an HMO?

Medicare supplement insurance, also called Medigap, is private health insurance designed to supplement Medicare. A premium is paid for this coverage which is age rated.

There are twelve standardized Medigap plans, A through L. In most states, you can go to any doctor or hospital that accepts Medicare without pre-authorization. Under plans C through J, days one through twenty are completely paid for by Medicare. For days twenty one through one hundred, the Medicare co-pay for 2010 is 7.00 which is covered by the Medigap policy. From day one hundred one and beyond, the patient is responsible for the full cost.

For Medicare Advantage plans such as an HMO like Secure Horizons, SCAN and Kaiser, the patients may have a co-pay from day eleven of 0. It is best check the benefits booklet or call the customer service department.

If someone goes to a facility without going to the hospital first, then you must private pay from day one.

Once the patient comes off Medicare reimbursement, if qualified, Medi-Cal will help to pay for the nursing home costs. If going to the facility directly from home, then, if qualified, Medi-Cal may help to pay for the nursing home costs from day one.

Please consult with a Medi-Cal specialist for more information and the exact procedures.

Copyright 2010 by Karl Kim

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Medicare Part A and B - What is the incompatibility between the Two Plans?

Hospice Of - Medicare Part A and B - What is the incompatibility between the Two Plans?. The content is good quality and useful content, Which is new is that you never knew before that I do know is that I actually have discovered. Before the distinctive. It is now near to enter destination Medicare Part A and B - What is the incompatibility between the Two Plans?.

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Medicare part A and B differ in discrete ways. Each plan has its own benefits that may be right for you, depending on what type of condition insurance you need. Part A is hospital insurance that is in case,granted by Medicare. It includes nursing homes, critical access hospitals, skilled nursing facilities and sick person care in hospitals. It does not include custodial care or long term care. Inexpressive insurance clubs act as agents for the federal government while paying and processing claims for Medicare. Part A commonly does not require a superior unless you or your spouse did not pay taxes for Medicare while working.

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How is Medicare Part A and B - What is the incompatibility between the Two Plans?

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One way that Medicare part A and B differ is what the plans cover. Part A covers blood transfusions, hospital stays, home condition services, skilled nursing facilities, and hospice care. Hospital stays include a semi-private room, as well as normal nursing, meals, and discrete supplies and services. Home condition services include medically critical part time care and services, and may include medical equipment. Skilled nursing premise stays must be linked to a determination received during a stay at a hospital. Hospice care is in case,granted for symptom operate and pain relief drugs, as well as medical services and grief counseling.

Part B is the other part of Medicare part A and B, and covers other aspects of Medicare. Part B is in case,granted by the federal government to those who are eligible for its benefits. It includes things that are not covered by part A like some home condition care services, occupational and corporeal therapies, and sick person care. It also covers other doctor's services that are medically necessary. Most individuals must pay a superior for part B. This is commonly deducted from the state you live in order to pay your deductibles or premiums.

Part B of Medicare part A and B covers preventive treatments, tests and other services that are coarse for patients of condition patients. It covers diabetic screenings if you have high blood sugar or high blood pressure. Lab services are in case,granted such as blood tests. Bone mass determination may be in case,granted as medically critical or every two years. Glaucoma tests are covered one a year if they are performed by an eye investigator that is legally authorized. Diabetic supplies are also included, such as lancet devices, monitors, therapeutic shoes and test strips. If prescribed by your doctor, you may also receive diabetic self supervision training.

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Medicare Frequently Asked Questions

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Straight talk. Answers to 3 FAQ's about Medicare and Medicare Supplement Insurance. You don't need to be a Medicare expert or devote hours reading info and researching online to understand your Medicare and Medicare Supplement options.

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How is Medicare Frequently Asked Questions

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Q: What is the difference between Original Medicare and Medicare Advantage (MA) Plans?

A: There are several key differences between Original Medicare and Medicare Advantage Plans. Original Medicare is your government Medicare. Medicare Advantage is private Medicare that takes the place of your government Medicare. You will have similar out-of-pocket expenses with an MA plan as you would with Original Medicare alone.

It is important to understand that in general an MA plan is the same coverage as Original Medicare. You may get some extra benefits such as dental or eyeglasses, and some of the plans include drug coverage as well, but the base coverage will be the same as original Medicare.It is not the same as Medicare plus a Medigap or Supplement Plan. You can not get a supplement plan to cover your out-of-pocket expenses when you are enrolled in an MA plan.

Q: What are my potential out-of-pocket expenses with my Medicare coverage?

A: Medicare itself is great coverage but there are some gaps in the coverage that many beneficiaries fill with a Medicare Supplement policy.

Medicare Part A covers hospital room and board, short-term skilled nursing care and hospice care.

There is a deductible for Part A. Currently the deductible is 32.00. This means that you will pay the first 32.00 before Medicare benefits are paid. This is not an annual deductible. It is a benefit period deductible. A benefit period starts the day you are admitted to the hospital and ends 60 days after you are released. It is possible that you could encounter the Part A deductible more than once in a year. After the deductible is met Medicare covers 100% semi-private room and board for 60 days. From day 61-90 the is a daily co-insurance of 3 per day. After 90 days Medicare provides coverage for an additional 60 lifetime reserve days with you paying a daily co-pay of 6.

Skilled nursing facility following a hospital stay of at least 3 days is covered by Medicare at 100% for the first 20 days. Days 21-100 have a 1.50 co-pay per day.

Hospice is covered by Medicare with very limited co-pays.

The deductibles and co-insurances increase from year to year.

Your exposure on the A side of Medicare are your deductible, and the various co-insurances mentioned above.In addition, Medicare doesn't cover the first 3 pints of blood.

Medicare Part B covers medical expenses in or out of the hospital such as doctor visits, inpatient and outpatient medical and surgical services and supplies.Diagnostic testing, speech and physical therapy, and durable medical equipment are Part B expenses.

There is a calendar year deductible for Part B. This year the deductible is 2.00. After you have met your deductible medicare covers 80% of approved amounts for covered services.

Your exposure on the B side of Medicare includes the deductible and 20% of approved amounts for covered services and any Part B excess charges. Part B excess charges are charges for covered services that exceed Medicare approved amounts.

Q: How can I limit my exposure and cover the gaps in my Medicare coverage.

A: You can supplement your Medicare coverage with a Medigap insurance policy.

There are 10 Medicare supplement policies that are approved by Medicare. All of the supplements have the same basic benefits.

Medicare supplement basic benefits for Medicare Part A cover all of your hospital co-insurances and will extend your covered days beyond Medicare coverage for and additional 365 days. The Part A deductible and skilled nursing co-insurance coverage are optional benefits.

Your supplement will automatically adjust to the changes in Medicare deductibles and co-pays from year to year.

Under Medicare Part B, Medicare Supplement basic benefits will cover your 20% co-insurance.

You can choose a supplement plan that includes optional benefits such as Part B deductible, Part B excess, and foreign travel emergency coverage.

Seek the guidance of a broker who specializes in Medicare to help you determine which of the 10 Medicare Supplement Plans best suits your needs.

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What Does Medicare Part-A And Part-B Pay For?

Reserve Hospice - What Does Medicare Part-A And Part-B Pay For?. The content is nice quality and helpful content, Which is new is that you just never knew before that I do know is that I have discovered. Before the unique. It's now near to enter destination What Does Medicare Part-A And Part-B Pay For?.

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The complicated world of Medicare can quickly be explained in simple ways as follows:

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How is What Does Medicare Part-A And Part-B Pay For?

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Medicare PART-A: This is the hospital portion of the plan, and it pays for the following

o Inpatient hospital care
o Hospice care
o Some skilled nursing care
o Home health care

Before we go any further, you also need to learn what "benefit period" is: Benefit period refers to the number of days you receive care in a hospital or skilled nursing facility. Medicare uses this count to determine the amount it will pay per a benefit period. Three factors determine your benefit period:

1. The length of stay in skilled nursing facility
2. The length of your stay in hospital
3. The length of release before you return to a skilled facility or a hospital

Your benefit period begins the day you are accepted to a hospital and continues as long as you: (1) Stay in a hospital (2) Transfer to a Medicare approved skilled care facility within 30 days of your stay. And it ends if you don't receive hospital or skilled nursing care for consecutive 60 days whenever you leave hospital or skilled nursing home care.

How Medicare pays for Part-A (remember, this is only the cost of your hospital or skilled care facility, it doesn't include any doctors, nurses or the cost of your prescription drugs.)
o Days 1 - 60: You pay ,068.00 as your deductible
o Days 61 - 90: You pay 7.00 per day as your co-pay
o Days 91 - 150: You pay 4.00 per day as your co-pay, up to 60 days. These 60 days are your Lifetime Reserves. When you exhaust them, they will not renew.
o Days 151 and over: If you have any Lifetime Reserves left, you will pay 4.00 per day until you exhaust your Lifetime Reserves. If you don't have any Lifetime Reserves left, you will pay all Part-A expenses after the 90th day.

How Medicare pays for Skilled Nursing Care
o Days 1 - 20: You pay nothing
o Days 21 - 100: You pay up to 1.50 per day as your co-pay
o Days after 101 and over: You pay all costs

Medicare Part-B: This is the medical insurance portion of Medicare and it pays benefits for doctors' services, outpatient hospital services, medical services and supplies.
o You pay .40 monthly premium (automatically taken out of your social security check)
o You pay 5.00 as your deductible
o After the deductible, you pay 20%, and Medicare pays 80%
o You pay 15% more for assigned specialist

Please note that the explanation of the rules for Medicare paying for Part -A and Part - B are beyond the scope of this article.

It should also be mentioned that since Medicare has considerable benefit limitations, there are private insurance policies called Medigap Insurance Plans where these insurance policies complement the gaps that Medicare does not cover. It is highly recommended to consult a Medicare Specialist to coordinate which one of these Medigap Plans is suitable for your personal needs.

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How Much Does Medicare Part A Pay?

Reserve Hospice - How Much Does Medicare Part A Pay?. The content is good quality and helpful content, That is new is that you just never knew before that I know is that I have discovered. Before the unique. It's now near to enter destination How Much Does Medicare Part A Pay?.

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Most of us know that The Part A program provides compensation for healthcare or medically needed services for hospitalization, however there are certain caps in benefits you should be aware of in order to make precautionary arrangements. To conceptually grasp and understand Part A, you need basic information about the programs payment allocation, for hospitals, nursing facility, or home health care, as well as benefit periods and coinsurance amounts. How much Medicare Part A pays depends on how many days of inpatient care you have during what is called a benefit period or spell of illness.

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A benefit period or spell of illness refers to the time you are treated in a hospital or skilled nursing facility, or some combination of the two. The benefit period begins the day you enter the hospital or skilled nursing facility as an inpatient, and continues until you have been out for 60 consecutive days. If you are in and out of the hospital or skilled nursing facility several times but have not stayed out completely for 60 consecutive days, all your inpatient bills for that time will be figured as part of the same benefit period.

Hospital Reimbursement.

Medicare Part A pays only certain amounts of hospitalization for any one benefit period.

The Deductible.

For each benefit period, you must pay an additional amount before Medicare will pay anything. This is called the hospital insurance deductible. The deductible is increased every January.

First 60 Days.

For the first 60 days you are an inpatient in a hospital during one benefit period, Part A hospital insurance pays all of the cost of covered services. However, non-essentials, such as televisions and telephones, are not covered. You pay only your hospital insurance deductible within this time frame. If you are in more than one hospital, you still pay only one deductible per benefit period and Part A covers 100% of all your covered cost for each hospital.

Days 61 - 90.

After your 60th day in the hospital during one spell of illness, and through your 90th day, each day you must pay what is called a coinsurance amount toward your covered hospital cost. Part A of Medicare pays the rest of covered cost.

Reserve Days

Reserve days are a last resort coverage. They can help pay for your hospital bills if you are in the hospital more than 90 days in one benefit period, however the payment is quite limited. If you are in the hospital for more than 90 days in any one spell of illness, you can use up to 60 additional reserve days of coverage. During those days, you are responsible for a daily coinsurance payment. You do not have to use your reserve days in one spell of illness, however you can split them up and use them over several benefit periods. You have a total of only 60 reserve days in your lifetime. Whatever reserve days you use during one spell of illness are gone for good. In the next benefit period, you would have available only the number of reserve days you did not use in previous spells of illness.

Psychiatric Hospitals.

Medicare Part A hospital insurance covers a total of 190 days in a lifetime for inpatient care in a specialty psychiatric hospital. If you are already an inpatient in a specialty psychiatric hospital when your Medicare coverage goes into effect, Medicare may retroactively cover you for up to 150 days of hospitalization before your coverage began. In all other ways, inpatient psychiatric care is governed by the same rules regarding coverage and co-payments as standard hospital care. There is no lifetime limit on coverage for inpatient mental health care in a general hospital. Medicare will pay for mental health care in a general hospital to the same extent as it will pay for other inpatient care.

Skilled Nursing Facilities.

Despite the common misconception that nursing homes are covered by Medicare, the truth is that it only covers a limited amount of inpatient nursing care.

For each benefit period, Medicare will cover only a total of 100 days of inpatient care in a skilled nursing facility. For the first 20 of 100 days, Medicare will pay for all covered cost, which will include all basic services excluding television, telephone, or private room charges. For the following 80 days, the patient is personally responsible for a daily co-payment; Medicare pays the rest of covered cost. Reserve days, available for hospital coverage, do not apply to a stay in nursing facility. After 100 days in any benefit period, you are on your own as far as Part A hospital insurance is concerned. However, if you later begin a new benefit period, your first 100 days in a skilled nursing facility will again be covered.

Home Health Care.

Medicare Part A pays 100% of the cost of your covered home health care when provided by a Medicare approved agency, and there is no limit on the number of visits to your home for which Medicare will pay. Medicare will also pay for the initial evaluation by a home care agency, if prescribed by your physician, to determine whether you are a good candidate for home care. However, if you require durable medical equipment, such as a special bed or wheel chair, as part of your home care, Medicare will pay only 80%.

Hospice Care.

Medicare pays 100% of the charges for hospice care, with two exceptions. First, the hospice can charge the patient up to .00 for each prescription of outpatient drugs the hospice supplies for pain and other symptomatic relief. Second, the hospice can charge the patient 5% of the amount Medicare pays for inpatient care in a hospice, nursing facility, or the like every time a patient receives respite care. There is no limit on the amount of hospice you can receive. At the end of the first 90 day period of hospice care, your doctor will evaluate you to determine whether you still qualify for hospice, meaning your disease is still considered fatal and you are still estimated to have less than 6 months to live. A similar evaluation is made after the next 90 day period, and again every 60 days thereafter. If your doctor certifies that you are eligible for hospice care, Medicare will continue to pay for it even if it exceeds the original six month diagnosis. And if your condition improves and you switch from hospice care back to regular Medicare coverage, you may return to hospice care whenever your condition warrants it.

By knowing exactly what Medicare Part A pays, an educated decision can me made as far supplementing the gaps.

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