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Medicare and Medicaid

What Is Medicare?

Medicare is a federal health insurance program providing health care benefits to all Americans age 65 and over, as well as some disabled individuals under age 65. Eligibility for Medicare is linked to Social Security and railroad retirement benefits.

Medicare has co-payments and deductibles. A deductible is an initial amount you are responsible for paying before Medicare coverage begins. A co-payment is a percentage of the amount of covered expense you are required to pay.

What Are Medicare's Coverage Options?

Medicare has two parts:

  1. Part A (hospital insurance)
  2. Part B (medical insurance)

Part A Medicare coverage includes:

  • All normal hospital services.
  • Skilled nursing facility care.
  • Home health services, including a visiting nurse or a physical, occupational, or speech therapist.
  • Medical supplies.
  • Hospice services.

Part B Medicare coverage includes:

  • Eighty percent of reasonable charges from doctors and other health care professionals (after the annual deductible is met).
  • Medically necessary ambulance services.
  • Physical, speech, and occupational therapy.
  • Home health care services (physician certification is necessary).
  • Medical supplies and equipment.
  • Transfusion of blood and blood components provided on an outpatient basis.
  • Outpatient surgery.

Part B Medicare benefits require that you pay a monthly premium. You must also be entitled to Part A benefits to receive Part B benefits.

Medicare part D is supplemental prescription drug coverage that is usually not part of a government program and is purchased separately from Medicare.

Medicare Coverage of Skilled Nursing Care Facilities

In order to receive care in a nursing home under Medicare:

  • You must have had a three-day hospital stay prior to admission into the skilled nursing facility.
  • You must be admitted into the skilled nursing facility within 30 days of discharge from the hospital.
  • You must enter the skilled nursing facility for treatment of the same condition for which you were hospitalized.
  • You must require daily skilled care.
  • The condition must be one that can be improved by admission to the facility.
  • The facility must be Medicare-certified.
  • Your doctor must write a care plan. The care plan must be carried out by the skilled nursing facility. (Once the patient meets the level of functioning laid out in the care plan, Medicare will no longer pay for services.)

Medicare Coverage of Home Care

In order to receive home care under Medicare:

  • You must be homebound.
  • The doctor must certify a plan of care.
  • Care must be needed on a non-continuous basis.
  • Care cannot exceed 35 hours per week or 8 hours per day.
  • Physical or speech therapy must be provided on a "necessary and reasonable" basis. There are no restrictions on the number of days or hours per week of these therapies.
  • If you qualify for home health care, you are entitled to a home health aide to provide some personal care.

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