Financial Planning for Caregivers
What Is Medicare?
Medicare is a federal health insurance program providing healthcare benefits to Americans 65 and older, as well as to some disabled individuals under age 65, and people of any age with permanent kidney failure requiring dialysis or kidney transplant. Eligibility for Medicare is linked to Social Security and railroad retirement benefits.
Medicare has co-payments and deductibles. A deductible is an initial amount the patient is responsible for paying before Medicare coverage begins. A co-payment is a percentage of the amount of covered expense the patient is required to pay.
What Are Medicare's Coverage Options?
Medicare has several parts.
Part A Medicare covers hospital bills and includes:
- Inpatient hospital care
- Skilled nursing facility care (not custodial or long-term care)
- Home health services, including a visiting nurse, or a physical, occupational, or speech therapist
- Blood that you receive at a hospital or skilled nursing facility during a covered stay
- Medical supplies
- Hospice services
- Mental health care given in a hospital
Part B Medicare deals with doctors' bills and includes:
Doctor charges and preventive services
- Medically necessary ambulance services
- Physical, speech, and occupational therapy
- Home health care services (physician certification is necessary)
- Medical supplies and equipment such as wheelchairs, hospital beds, oxygen, and walkers
- Transfusion of blood and blood components provided on an outpatient basis
- Outpatient medical/surgical supplies and services
- Outpatient mental health
Part B Medicare benefits require payment of a monthly premium. A patient must also be entitled to Part A benefits in order to receive Part B benefits.
Part C refers to Medicare Advantage, which are managed care insurance plans you can buy from private insurers to replace your traditional Medicare coverage. They include Medicare HMOs, Medicare PPOs, Medicare Special Needs Plans, and Medicare Private Fee-for-Service Plans.
Part D provides some coverage of prescription drugs. Medicare works with insurers and other private companies to offer many different plans. Expect to pay a monthly premium and part of the prescription cost.
Medicare Coverage of Skilled Nursing Care Facilities
If nursing home care becomes necessary, your loved one may be eligible for Medicare. In order to receive care in a skilled nursing home under Medicare:
- Plans generally require them to have had a three-day hospital stay prior to admission into the skilled nursing facility. There are exceptions, however, and the patient's insurance provider should be consulted to determine whether these restrictions apply.
- The patient must meet specific criteria to receive treatment. The patient's doctor or nurse will help him or her to determine if the criteria are met.
- The patient must be admitted into the skilled nursing facility within 30 days of discharge from the hospital.
- The patient must enter the skilled nursing facility for treatment of the same condition for which he or she was hospitalized.
- The patient must require daily skilled care.
- The condition must be one that can be improved.
- The facility must be Medicare-certified.
- The patient's doctor must write a care plan. The care plan must be carried out by the skilled nursing facility. (Once the skilled needs are met, Medicare will no longer pay for services.)