Medicare is a National Health Insurance Program administered by the Health Care Financing Administration (HCFA).

Benefits are for:

  • People 65 years and older
  • Some people with disabilities under age 65
  • People with end stage renal disease (permanent kidney failure requiring dialysis or a transplant)

Medicare has two parts:

  • Part A (Hospital Insurance)
  • Part B (Medical Insurance)

Part B (Medical Insurance)

Medicare Part B covers physician services, outpatient hospital care, ambulance services, prosthetic devices, medical equipment and supplies.

  • Single individuals with an income of $85,000 and a married couple with less than $170,000 (2010 rate) pay the Medicare Part B premium of $96.40 per month.
  • Single individuals with income greater than $85,000 and less than $107,000 or married with income greater than $170,001 and less than $214,000 pay the Part B premium of $154.70 per month.
  • Single individuals with income greater than $107,001 and less than $160,000 or married with income greater than $214,001 and less than $320,000 pay Part B premium of $221.00 per month.
  • Single individuals with income greater than $160,001 and less than $214,000 or married with income greater than $320,001 and less than $428,000 pay Part B premium of $287.30 per month.
  • Single individuals with income greater than $214,000 or married with income over $428,000 pay Part B premium of $353.60 per month.

Part A (Hospital Insurance)

Medicare Part A primarily provides coverage for inpatient hospital care. It also provides hospice care. Limited coverage is provided for skilled nursing homes and home health. No coverage is provided for assisted living.

Most seniors become eligible for Part A coverage when they reach age 65 and become entitled to Social Security retirement benefits. They do not have to pay a monthly premium for Part A because they or a spouse paid Medicare taxes while they were working. Some seniors (such as those who have not completed the mandatory number of working quarters for social security benefits) enroll on a voluntary, premium-paying basis.

Medicare Part A begins when someone enters a hospital. Medicare Part A has hospital deductibles.

  • First 60 days, Medicare pays all but $1,100.
  • Days 61 to 90, Medicare pays all but $275/day.
  • Days 91 to 150, Medicare pays all but $550/day.
  • Beyond 150 days, Medicare pays nothing.

Remember, Medicare is a health insurance program aimed at covering acute health care costs, such as hospitalization (Part A) and periodic doctor visits (Part B). It does not cover most nursing home fees, nor does it offer extensive home health care for the chronic ills often experienced with age.

What does Medicare cover for nursing home care?

Very little!

Medicare Part A helps pay for inpatient skilled nursing care in a Medicare-participating Skilled Nursing Facility (SNF) or a rehabilitation service facility following a three-day hospital stay if a person’s condition requires skilled nursing services or rehabilitation services, such as Physical Therapy (PT), Occupational Therapy (OT) and Speech Pathology (SP).

Doesn’t everyone get 100 days coverage in a SNF?

No. Medicare will pay up to 100 days.

  • Days 1-20: Medicare Part A pays 100%.
  • Days 21-100: Medicare pays all but the daily co-insurance amount that is the patient’s responsibility.

After the first 20 days, a person must be making “reasonable, measurable progress” in their rehabilitation or continue to need “skilled nursing” care to continue on Medicare benefits. Once a person reaches his or her “maximal potential,” Medicare benefits end. This can happen any time after the first 20 days.

Medicare Part A provides no coverage beyond 100 days.

Is Home Health Care covered under Medicare?

Yes!

Medicare pays 100% for all covered and medically necessary home health services under Part A (or Part B if beneficiary does not have Part A) as long as the beneficiary continues to meet the coverage requirements. Medicare will pay for an unlimited number of in-home visits during an unlimited period, as long as it is medically necessary and coverage requirements are met. It is the intent of home health visits under Part A to deliver skilled medical attention to homebound patients. Home health care is not available for chronic illness or to help with Activities of Daily Living (ADL).

Requirements include:

  • Home Health Care Agency must be Medicare certified.
  • Patient must be under a doctor’s care, and the doctor must authorize medical treatment.
  • Patient must be in need of skilled care and be confined to his or her home.

Hospice care is a service provided to terminally ill people with a life expectancy of six months or less. Medicare defines a hospice as a public agency or a private organization whose primary role is to provide pain relief and symptom management to terminally ill patients. This benefit does not generally cover inpatient room or board charges.

Medicare requirements include:

  • Doctor certification that a patient is terminally ill and has a life expectancy of less than six months
  • A Medicare-certified hospice program must provide care

Medicare pays 100% of most covered services. Medicare pays for up to two 90-day periods, one 30-day period and a fourth unlimited extension period. The beneficiary pays a small co-insurance fee for outpatient drugs and inpatient respite care.

Visit Medicare.gov for more information on Medicare.

Source: Barbara Horstmeyer, Certified Senior Advisor, Senior Planning Group