As Americans age, and enter retirement, or as their parents age, and can no longer care for themselves, a growing question many face is how to navigate the ins and outs of the Medicare coverages available to you. In order to better understand what you can do and how to go about claiming and planning for your benefits under the Medicare system, the following information should be helpful. If this article does not answer your specific questions, then more information is available at Medicare.gov; the official Medicare website.
What does Medicare Part A cover?
According to the official information, Medicare Part A will cover the following types of medical treatments, and it should be noted that your Medicare Part A benefits are the ESSENTIAL benefits for major care:
1. Inpatient Care in hospitals: This means that when you are ADMITTED to a hospital, Medicare Part A should cover your benefits.
2. Critical Access Hospitals: This is also an inpatient treatment, but of a kind that differs from other inpatient admissions.
3. Skilled Nursing Facilities: This IS NOT custodial care or long-term care, but rather a facility providing nursing services that cannot be obtained elsewhere. You should think of custodial care as “nursing home” nursing and long-term care in a similar light.
4. Hospice Care: Hospice is usually limited to the terminally ill or critically ill and is limited to very rare instances of coverage in Medicare, however, questions can be directed to your physician or other medical care provider, and this will be discussed later in the article.
5. SOME Home Health Care: Because some patients who suffer from chronic illnesses common among the elderly, and because the cost-effectiveness of admitting all of them as inpatient or Skilled Nursing admissions would be too expensive, Medicare has wisely chosen to cover some limited Home Health Care needs to prevent costs of emergent admissions when these patients go without care and end up in the E.R.. Typical expenses may be related to dialysis or even some maintenance of diabetic equipment or oxygen equipment and so forth.
Who is eligible for Medicare Part A benefits?
This question is not as easily answered, since there are two types of available plans, the PREMIUM FREE plan, and the PREMIUM BASED plan. Most folks fit into the premium free plan, because they are retired, are over 65 and have contributed to the Medicare plan from their wages, or their spouse has contributed to the plan through his r her wages.
In addition, those UNDER the age of 65 may qualify if they suffer from certain disabilities, and persons with End-Stage Renal Disease of ANY age (permanent kidney failure requiring dialysis or a kidney transplant) automatically qualify for Medicare.
However, if you are not in one of these categories, you may still obtain Medicare Part A benefits by PURCHASING them if you (or your spouse) are someone who didn’t work or didn’t pay enough to Medicare to get the premium free coverage while you were working, and are now over 65, OR if you are disabled, but no longer qualify for benefits because you have returned to work.
The cost is negligible for these plans in comparison with standard health insurance, BUT if you or your family member does not have enough, there should and often times are state plans to assist you in paying for your Medicare premiums.
The most important item of this section is that you will receive a CARD from the Medicare plan that tells you what benefits you have. If you don’t have a card, then you will face many obstacles in getting your benefits paid quickly when you visit the doctor. Keep your card with you at all times, and make sure to refrain from lending it to anyone at any time for any reason. If you have designated someone as your legal guardian, or if you are the legal guardian of a Medicare patient, then you should make sure that the guardian has access to or possession of the card in an emergency.
What specific benefits are payable, and how are they paid?
Hospital Stays will NOT cover a private room. They will only cover up to the semi-private rate. This is no different than most commercial insurance plans, and these rates are monitored and strictly enforced through regulatory agencies, so you should not have to worry too much about this. What is NOT covered is a telephone or television in your room. In limited instances, and where MEDICALLY NECESSARY, private rooms can be covered. Be aware that this does not mean you can get a private room because of any sense of embarrassment or anxiety over sharing a room because of your physical symptoms. It will only stand up to a strict definition of the medical necessity. If you are not sure, as always, ask your medical care provider if they think it is something that would require private rooms. This coverage will ALSO cover your meals, general nursing, and other hospital services and supplies. Once again, the terms services and supplies mean things like medications, new dressing for your wound, catheters, etc. It will not include items from the hospital gift shop, which have been billed to your room.
A note about inpatient mental health care – Medicare limits your total inpatient mental health care to 190 days during your lifetime. That is a hard & fast rule. If there are accompanying medical conditions that need treatment as primary diagnoses, then the medical condition is usually claimed as the reason, but no special accommodation is normally made for any accompanying mental health issues unless necessary for the treatment of the patient and the safety and convenience of the staff and other patients. As always, if you are not sure, as the medical health professional who is the primary caregiver for the patient.
Skilled Nursing Facility care will also cover a semiprivate room, meals, skilled nursing and rehabilitative services as well as other services and supplies, but ONLY AFTER A RELATED 3-Day hospital stay. In other words, if the patient was admitted for a stroke, and then needs to rehabilitate after the stroke, then the skilled nursing facility would cover the benefits, as it is presumed that the patient would have been admitted for at elast 3 days due to the stroke. This is not the only diagnosis covered, but it is a common one, that all should be able to relate to and understand.
Home Health Care services are limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy, and speech-language pathology that are ORDERED by your doctor and PROVIDED by a Medicare-certified home health agency. That means that you can’t pick and choose who gives you the care, but that you have the added assurance that the Medicare certification has vetted out fly-by-nighters who you can’t trust in your home. Also included, and which you may not be aware of are medical social services, durable medical equipment (like oxygen equipment, wheelchairs, hospital beds and walkers), medical supplies and other services. Thus if the question is whether or not you should try to put your disabled husband or wife in a convalescent home or try to care for him or her in your home, allowing them the dignity of remaining with those they love, then these services may be available to help you figure out how it can be done, and in a manner in which you don not have to take the entire task upon yourself.
Hospice care services for persons with terminal illnesses will include coverage for drugs for symptom control and pain relief, as well as medical and support services from a Medicare-Approved Hospice facility. Remember that support services can mean family counseling for those coping with the grief of a loss that could come at any time. This Hospice care is USUALLY given in home as well, and in limited circumstances may be in an inpatient facility as well. Even for the in-home hospice patients, short term inpatient stays may be covered when there is a need for more advanced care than the hospice services can provide in the home.
What types of Plans are available to me?
As with standard insurance programs, Medicare even offers some variety as to the type of plan you take, in order to offer you some flexibility in how your costs are handled under the plan. There are traditional pay-as-you-go plans, which require that you pay the bills and then submit them to Medicare for repayment, or which will require that you play 20% of the negotiated fee under the Medicare Schedule, and then there are also plans known as Medicare Advantage Plans, which mean lower out-of-pocket costs and expanded services and coverages, but which require you to stay in a network of providers exactly as you would in a PPO plan or an HMO plan, as well as a PFF plan. If you do not know what any of these acronyms mean, they are easily explained and available elsewhere on the website, or through the resources listed below.