Financial Planning for Caregivers
What Is Medicare? continued...
Medicare Coverage of Home Care
In order to receive home care under Medicare:
- The patient must be homebound.
- The doctor must certify a plan of care.
- Skilled nursing care must be needed on an intermittent (not continuous) basis.
- Care cannot exceed 35 hours per week or eight 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 a person qualifies for home health care, he or she is entitled to a home health aide to provide some personal care.
Visit the Medicare web site for the most up-to-date rules and regulations.
What Is Medicaid?
Medicaid is a joint federal-state health insurance program providing medical assistance primarily to low-income Americans who have limited resources. It is also available to people under 65 if they are blind or disabled. The purpose of Medicaid is to provide preventive, therapeutic, and remedial health services and supplies that are essential to attain an optimum level of well-being.
How Do People Receive Medicaid Benefits?
There are two ways to receive Medicaid:
- Supplemental Security Income (SSI) -- People who receive a cash grant under SSI and Aid to Dependent Children are automatically eligible for Medicaid benefits.
- Medicaid "spend-down" -- This is similar to a deductible or a co-payment that a patient must pay every month. Once the patient meets his "spend-down" amount, the patient is eligible for Medicaid for the remainder of the month.
Who Is Eligible for Medicaid?
Medicaid eligibility requirements depend on financial need, low income, and minimal assets. In determining Medicaid eligibility, officials do not review rent, car payments, or food costs. Officials only review medical expenses, which include:
- Care from hospitals, doctors, clinics, nurses, dentists, podiatrists, and chiropractors
- Medical supplies and equipment
- Health insurance premiums
- Transportation to get medical care
The four eligibility tests required to receive Medicaid include:
- Categorical -- A patient must be age 65, blind, or disabled.
- Non-financial -- A patient must be a U.S. citizen and a state resident. A patient also must have a Social Security number.
- Financial -- A patient's total gross income, personal assets, and property will be evaluated and must meet a certain standard. This amount varies from state to state.
- Procedural -- A patient must complete and sign an application and have a personal interview with a Medicaid official.
Each eligible Medicaid recipient receives a monthly Medical Identification card. The card is valid for one month only.
Medicaid coverage varies from state to state. For specific coverage guidelines, contact your state's Department of Human Services. Generally, Medicaid benefits include:
- Transportation -- This may include ambulance services when other means of transportation are detrimental to the patient's health or may include transportation to and from the hospital at time of admission or discharge when required by the patient's condition. Transportation also may cover trips to and from a hospital, outpatient clinic, doctor's office, or other facility when the doctor certifies the need for this service.
- Ambulatory centers -- Ambulatory health care centers are private corporations or public agencies that are not part of a hospital. They provide preventive, diagnostic, therapeutic, and rehabilitative services under the direction of a physician. Ambulatory services covered by Medicaid include dental, pharmaceutical, diagnostic, and vision care.
- Hospital services -- These services include inpatient hospital care up to 60 days for an illness. Private hospital rooms are covered only when the illness requires the patient to be isolated for his or her own health or the health of others. Outpatient preventive, therapeutic, and rehabilitative services also are covered. So are professional, laboratory and radiology services.
- Medical supplies and medications -- These include general medical supplies (when prescribed by a physician), as well as medications prescribed by a physician, dentist, or podiatrist. Durable medical equipment (such as hospital beds, wheelchairs, side rails, oxygen administration apparatus, and special safety aids, etc.) also is covered.
- Home health care -- These services include those provided by a visiting nurse, home health aide, or physical therapist.
- Skilled nursing facilities -- Skilled nursing facilities and intermediate care facilities (providing short-term care for a patient whose condition is stable or reversible) are covered through Medicaid with a doctor's authorization.