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There is a common misconception that Medicare and Medicaid pay for an unlimited amount of long-term care. As this is not the case, we have provided a concise summary of the long-term care coverage patients and their families can expect from each of these programs. Whether you are considering Fundamental or another long-term care provider, this information will help you prepare for admission to a long-term care facility.

Medicare is a government health insurance program for people age 65 and over, as well as certain Americans who are disabled or have kidney disease. To receive benefits, medical services provided must meet Medicare standards, which normally include approval by a qualified physician. In order to be eligible, a Medicare-certified provider such as a hospital or other health care provider, who, like Fundamental, has been approved to participate in the program, must deliver the services. Below is a very brief description of Medicare benefits by health care setting.

Medicare Part A

  • Medicare Part A pays all or part of the cost for a 90-day portion of inpatient hospital stays per benefit period. The patient is required to pay a deductible at the onset of the hospital stay and a co-pay during days 61-90.
  • In order for Medicare Part A to pay for skilled nursing facility care, the patient must have a preceding hospital stay of at least 3 days, with a transfer to the nursing facility within 30 days of the hospital discharge. Medicare Part A covers up to 100 days of skilled nursing care per benefit period. All of the services provided must meet Medicare’s skilled criteria in order to be covered. The first 20 days of the benefit period are paid completely by Medicare. The next 80 days of skilled nursing care require a patient co-pay. In order to qualify for Medicare benefits you must meet the skilled nursing needs and continue to progress. 100 days is the maximum number of days per benefit period. You must be out of a skilled facility and/or not receiving skilled care for 60 consecutive days in order to regenerate your benefits.
  • Medicare Part A covers most of the cost of hospice care if a terminally ill individual chooses hospice in a Medicare-certified program instead of standard Medicare benefits.

Medicare Part B

  • As an enrollee of Medicare Part A, the patient is automatically enrolled in Medicare Part B unless they specify otherwise with the Social Security office. Unlike Medicare Part A, the patient must pay premiums to receive Part B coverage. Part B coverage is voluntary and the patient can choose to withdraw at any time.
  • As a participant in the Medicare Part B program, the patient is responsible for a $124 deductible each calendar year as well as 20 percent of all Medicare approved charges beyond the deductible. Medicare Part B will pay the remaining 80 percent of the charges related to:
  1. Medical and surgical procedures the patient receives in a physician's office, a hospital, a skilled nursing facility, or at home;
  2. Diagnostic tests and procedures related to treatment;
  3. The medical opinion of a second physician when appropriate;
  4. Services received in an emergency room or outpatient clinic;
  5. Mental health care in a hospital outpatient setting;
  6. Medically necessary ambulance transportation;
  7. Qualified Durable Medical Equipment (e.g., oxygen equipment and wheelchairs);
  8. Outpatient physical, occupational and speech therapy;
  9. Other designated services.

Medicare Part D

New in 2006, for those patients enrolled in Medicare A or B, Medicare provides prescription drug coverage. Available under Part D are both standard benefits and low income benefits for patients with limited savings and income. There is an annual deductible and a monthly premium for this benefit, as well as a copay. Patients must enroll in one of Medicare’s available prescription drug plans to receive these benefits.

Medicaid is a state and federally funded program that provides payment for health-related services including those provided in a nursing facility. To qualify for Medicaid coverage a person must meet certain income, asset, and medical need requirements. Each State administers its own unique Medicaid program within certain federal guidelines. The services covered, as well as the eligibility requirements for Medicaid, vary from state to state. Some of the basic federal eligibility requirements for nursing facility services with which each state program must comply include, but are not limited to the following:

  • The patient must be 21 years or older, and a US citizen or resident alien.
  • The patient must have a medical need for nursing facility services.
  • The patient's monthly income and countable assets must not exceed the eligibility limits set by the state. (Note that the patient may retain his/her residence and may still qualify for Medicaid if he/she plans on returning to the residence, or if his/her spouse or a dependent person is residing there.)

Medicaid coverage will continue as long as the patient continues to meet all the eligibility requirements, including those identified above. Fundamental facilities, as well as most other nursing facilities, will assist with the entire Medicaid application process.

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