Facts About Medicare and Medicaid

Medicare Part A, Medicare Part B, deductibles, coinsurance, Medicaid . . . health care payment can be confusing.

This web page offers a simple overview of the types of health care costs Medicare and Medicaid cover specific to skilled nursing facilities. Understanding health care payment and coverage will help you to make more informed decisions for you or your loved one.

What is Medicare?

Medicare is a Federal health insurance program for people age 65 and older, individuals who are permanently disabled for at least 24 months, or those who have End Stage Renal Disease. Anyone who is eligible for Social Security benefits may qualify for Medicare.

Medicare benefits cover skilled nursing costs after a person has been in the hospital for three consecutive days and has been admitted to a nursing facility within 30 days of discharge. The patient must require post-hospital treatment that is certified by a physician as skilled nursing or rehabilitation treatment. Medicare coverage is divided into two parts: Part A (hospital insurance) and Part B (medical insurance).

What does Medicare Part A cover?

Overall, Medicare Part A helps pay for care in hospitals, skilled nursing facilities, hospice and some home health care. To find out current coinsurance amounts and days covered, please call 1-800-MEDICARE (1-800-633-4227).

What does Medicare Part B cover?

Medicare Part B covers 80% of necessary medical services and equipment including: physicians’ fees; physical, occupational and speech therapies; durable medical equipment (hospital beds and wheelchairs); x-rays and lab tests. The Medicare recipient or the recipient’s supplemental insurance policy must pay a 20% coinsurance amount for almost all items covered under the Medicare Part B program. To find out current premium amounts, please call 1-800-MEDICARE (1-800-633-4227).

The following services are not covered by Medicare Part A or Part B:

• Private-duty nursing

• Custodial care at home

• Most chiropractic services

• Care outside the United States

• Experimental procedures

• Custodial care in a nursing facility

• Most preventive care

• Acupuncture

There are many other insurance options that cover skilled nursing services not covered by Medicare, including Medigap, Medicare HMOs, supplemental and long-term care insurance. If you are covered by any of these types of insurance, consult your representative.

What is Medicaid and what costs does it cover?

Medicaid is a Federal as well as a State-funded program that provides financial assistance for medical services to low-income individuals of all ages. Services offered through this program do not require monthly premiums, but there are strict financial eligibility requirements. In addition, Medicaid may require you to pay a portion of your monthly Social Security income to the nursing home as partial payment for services (patient liability). There are different eligibility levels depending on the type of care necessary.  Your State Department of Human Services can provide more information on the current State requirements, rules and restrictions.

Medicaid covers the following:

• All care provided in a Medicaid-certified nursing facility

• Home health care including nursing care, physical therapy and related services

• Other home services such as homemakers and chore services

• Physician care

• Hospice care

• Community mental health services

• Prescription drugs

• Some assistive devices including eyeglasses, dentures and hearing aids

• The cost of some Medicare Part A and B premiums, deductibles and co-payments, depending on your financial eligibility

Glossary of Terms

Coinsurance - The payment required from Medicare recipients for medical services. Medicare Part B coinsurance is 20% of Medicare allowable services. To find out current coinsurance amounts and days covered, please call 1-800-MEDICARE (1-800-633-4227).

Deductible - The annual amount paid by Medicare Part B recipients for medical services each calendar year.

Fee-for-Service - The traditional method used to pay for medical services in which Medicare pays the physician, hospital or long-term care facility for each eligible service they provide.  Traditional Medicare is a fee-for-service program.

Medicare HMO - A Medicare-managed care or "Medicare + Choice" option in which members are typically required to receive their care from physicians, hospitals and long-term care facilities that participate in that particular HMO plan.

Medigap - Insurance policies sold by private insurance companies to cover some of the "gaps" in coverage created by costs not paid by traditional Medicare.

Network (or Panel) - A group of physicians, nurses and hospitals that have signed up to provide health care services for the members of a managed care plan.

Patient Liability - The amount a patient must pay for medical services received in a nursing facility under the Medicaid program.

Premium - The monthly amount a patient pays for health care coverage. Premium amounts for Medicare Part B are adjusted annually. Eligible individuals may have their premiums automatically deducted from their Social Security checks. To find out current premium amounts for Medicare Part B, call 1-800-MEDICARE (1-800-633-4227).

Provider - A person, facility, physician or hospital that provides health care services.

Traditional Medicare - A Federal health insurance program for people age 65 and older, individuals who are permanently disabled for at least 24 months, or those who have End Stage Renal Disease.

Conclusion

For more information about Medicare or Medicaid, call your Laurel marketing representative, your state Health Insurance Assistance Program or the Federal Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227).  The Laurel Health Care Company toll free number is 1-877-528-7352.