What Is Medicare and What Does It Cover?
Medicare is a federal health insurance program that gives benefits to Americans ages 65 and older. It also covers some disabled people under 65.
It has four parts, and they each cover different aspects of your loved one's care.
Part A covers inpatient services and supplies that he needs to treat a disease or condition. For most people, Medicare Part A is free. That includes things like:
- Hospital care
- Skilled nursing facility care for a limited time. This includes things like getting an injection. It doesn't include help with daily tasks such as bathing and getting out of bed.
- Home health services, such as a visiting nurse or a physical, occupational, or speech therapist
- Blood transfusions at a hospital or skilled nursing facility
- Medical supplies
- Hospice care that keeps a sick person comfortable at the end of his life
- Mental health treatment given in a hospital
Part B requires a monthly premium and covers outpatient care like doctor visits and:
- Preventive services to keep a person healthy
- Ambulance rides
- Physical, speech, and occupational therapy
- Medical supplies and equipment such as wheelchairs, hospital beds, oxygen, and walkers
- Blood transfusions if you don't need to stay overnight in a hospital
- Medical/surgical supplies and services for outpatients (you don't stay overnight in a hospital)
- Mental health care when you don't need to stay overnight in a hospital
Part C is also known as Medicare Advantage. These are insurance plans you buy from private insurers that are approved by Medicare. If you get one, you're still in the Medicare program, but you'll get your Part A and Part B benefits from the Medicare Advantage Plan and use only doctors and hospitals in the Plan’s network. You will still need to pay your Part B premium under a Medicare Advantage plan and some plans charge a monthly premium as well.
Medicare Coverage of Skilled Nursing Care Homes
Medicare offers some coverage, for a limited time, if your loved one needs to enter a skilled nursing care home. But there are certain conditions he has to meet in order get it, such as:
- He needs to have had a 3-day hospital stay before being admitted to the skilled nursing home. There are some exceptions though, so check the Medicare web site for details.
- He must be admitted into the skilled nursing home within 30 days of leaving the hospital.
- He needs to enter the skilled nursing home for treatment of the same condition that he was treated for in the hospital.
- He must need daily skilled care.
- The home must be Medicare-certified.
- His doctor must write a care plan.
Medicare Coverage of Home Health Care
Medicare pays for some home health care costs of your loved one. The requirements include:
- He must be homebound.
- His doctor must approve a treatment plan.
- He must need skilled nursing care, but not all the time.
- He doesn't need attention more than 35 hours a week or 8 hours a day.
What Is Medicaid?
Medicaid is joint federal-state health insurance that pays some medical costs for Americans with low incomes.
Coverage differs from state to state. For guidelines, contact your state's Department of Human Services.
Usually, the benefits include:
Transportation. Ambulance rides to and from the hospital. They can be for emergencies or simply needed to keep your loved one's condition stable. Medicaid may also cover trips to and from a clinic or doctor's office.
Ambulatory centers. These are facilities that are run by private companies and public agencies that are not part of a hospital. They offer preventive care, therapy, and rehab under the direction of a doctor.
Ambulatory services covered by Medicaid include dentists, pharmacists, and eye doctors.
Hospital services. These include stays of up to 60 days. Private rooms are covered only when he's got an illness that requires him to be kept away from other patients.
He's covered for "outpatient care," which means he doesn't need an overnight hospital stay.
Labs and image tests such as X-rays and MRIs are also covered.
Medical supplies and medications. These are covered when prescribed by his doctor, dentist, or podiatrist (foot doctor). Some medical equipment, such as hospital beds, wheelchairs, side rails, and oxygen tanks, is also covered.
Home health care. He's covered for visits by a nurse, home health aide, or physical therapist.
Skilled nursing homes. These and intermediate-care facilities (which provide short-term treatment for a patient whose condition is stable or reversible) are covered with a doctor's consent.
Long-term care. Medicaid is the largest payer of long-term care services. How these services are provided varies by your state. There are some programs that will provide for all health and housing needs through one program called the Program of All-Inclusive Care for the Elderly (PACE). States may provide more flexible care through home and community-based waivers. Some states even have programs to pay family caregivers to take care of Medicaid patients and help keep them out of nursing homes.