What Medicare Covers
As a caregiver with many responsibilities, you may find it very beneficial to know exactly what Medicare health insurance covers for your elderly parent who may require home health care, skilled nursing care in a facility, hospital care, hospice care, or physicians' and therapists' services. If you understand what Medicare covers in each situation, then you can help your parent manage the cost of the health care he needs and is entitled to.
Medicare is a federally funded health insurance program for United States residents 65 years and over. Medicare has two parts: Part A and Part B.
Most people get Part A automatically when they turn 65 and do not have to pay a monthly premium because they paid Medicare taxes while they were working. Part A is the hospital insurance that helps pay for inpatient hospital care, for care in skilled nursing facilities, for hospice care, and for some home care. For hospital stays Part A does not cover private-duty nurses or the extra cost of private rooms unless medically necessary, and personal services like television and telephone. The annual deductible for 2004 is $876 per patient. Part A covers the first 60 days of hospitalization and then requires a copayment of $219 per day for the next 30 days. This coverage begins anew with each benefit period. A benefit period begins after 60 days free of hospitalization and skilled nursing care. If a person is hospitalized between 90 days and 150 days, the copayment per day is $438 and only 60 of these extra days will be covered in a lifetime.
Part B is the medical insurance that helps pay for physicians' services, outpatient hospital care, and other services not covered by Part A such as physical and occupational therapy, some home care, and supplies when they are medically necessary and ordered by a physician. Part B is obtained only through enrollment. For 2004, the monthly premium for Part B is $66.60 and the deductible per year is $100. After the deductible, Medicare pays 80 percent of the cost. The monthly premium is usually deducted from the beneficiary's monthly Social Security payment.
Home health care is skilled nursing care and other health care services provided by a home health care agency (such as the Visiting Nurse Service of New York) to a patient at home for the treatment of an illness or injury. All four of the following criteria must be met before a patient can receive Medicare home health care.
- A doctor must decide that care at home is necessary and make a plan of care that the staff of the home health care agency will carry out. The doctor will work with the home health care nurse to decide what kind of services are needed (including medical equipment and special foods), how often the services are needed, and what type of health care professional should provide these services. The plan may also include what the doctor expects from the treatment. The doctor and home health agency staff will review the plan at least every 62 days to see if any changes are required. The patient will receive home health care as long as he is eligible and as long as the doctor says he needs it.
- The patient must need either intermittent (part-time) skilled nursing care (performed only by a licensed nurse or licensed practical nurse), or physical therapy, or speech language pathology services. There are limits on the number of hours per day and days per week the patient can receive skilled nursing care. Medicare allows the combined skilled nursing care and home health services to be fewer than 7 days each week or fewer than 8 hours each day over a period of 21 days or less. (Once the patient is receiving home care, intermittent coverage includes services that total fewer than 8 hours per day and 28 or fewer hours per week.)
- The patient must be homebound. This means she is normally unable to leave home except for infrequent short visits or to get outside medical care.
- The home health agency providing the care must be approved by the Medicare program.
Medicare coverage for home health care
- Skilled nursing care on a part-time basis.
- Home health aide care on a part-time basis. The home health aide services must be part of the home care for the patient's illness or injury. This includes personal care such as bathing, dressing, help with eating. Medicare does not pay for home health aide services unless the patient is getting skilled nursing care or therapy.
- Physical therapy (includes exercise to regain movement and strength to a body area), speech language pathology services (includes exercises to regain speech skills), and occupational therapy (helps patient become able to do usual daily activities).
- Medical social services (includes counseling to help cope with an illness or finding resources in the community).
- Medical supplies (includes wound dressings but not drugs or biologicals).
- Durable medical equipment (pays 80 percent of the approved amount for equipment like wheelchairs and walkers).
- Medicare does not cover 24-hour-a-day care at home, prescription drugs, meal delivery, homemaker services like shopping and laundry.
Before the care begins, the home health agency must inform the patient how much of the bill Medicare should pay. The agency must also explain in writing what items are not covered by Medicare and how much their cost will be. The agency sends bills to Medicare which pays the full approved cost of all covered home health care visits.
If your parent or elderly relative has a Medicare managed health plan, which covers all Medicare Part A and Part B health care including home health care, you need to call the plan's benefit administrator to learn the plan's rules and what the costs will be for coverage.
Part A
Medicare coverage for skilled nursing facility
- First 20 days in benefit period; care must be related to a hospital stay of at least 3 days within a 30-day period.
- Copay of $105 for each benefit period between the 21st day and the 100th day.
- No coverage after 100 days.
- Skilled nursing and all therapists (speech, physical, occupational)
- Medications and meals.
- Medicare does not cover custodial care (bathing, dressing) or extra charge for private room.
Medicare coverage for hospice care
- All medical and nursing care, medical supplies, short-term hospitalization, home care, and counseling
- Portion of the cost of drugs and inpatient respite care
Medicare coverage for psychiatric care
- 190 days over a lifetime in a free-standing facility (hospital) as opposed to a wing of a hospital
Part B
Medicare coverage for physicians' fees
- Most doctors' bills, including second opinions and some care from Medicare-approved special practitioners such as nurses, social workers, physicians assistants.
- Medicare does not cover charges in excess of approved fees and routine physical exams, dental care, and some chiropractic and foot care.
Medicare coverage for outpatient hospital care
- Medical services and supplies, including emergency room visits, one-day surgery, and some rehab
- Mental health services require 50 percent copayment.
Medicare coverage for rehabilitation and therapy
- Limited outpatient physical, speech, and occupational therapy.
- Medicare does not cover any therapy above $900.
Medicare coverage for lab services, medical equipment and supplies
- Blood and urine tests, x-rays, scans, biopsies.
- Medically necessary equipment such as wheelchairs, walkers, oxygen equipment.
- Prosthetic devices.
- Medicare does not cover eyeglasses, hearing aids, dentures.
Medicare coverage for preventive care
- Mammograms and pap smears, pneumococcal vaccine, flu vaccine, hepatitis B vaccine, diabetes services, bone density test, colorectal cancer screening, prostate cancer screening.
- Medicare does not cover routine screenings or physical exams, vision and hearing exams.
Medicare coverage for ambulance service
- Cost of service when other transportation would endanger the patient's health.
For coverage questions regarding any other health care service a Medicare beneficiary might need, call 1-800-633-4227; or go to www.medicare.gov.
Medicare services need to be ordered by a doctor.
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