Medicare and Medicaid

Medicare

Medicare is a government health insurance program for people age 65 and over, as well as certain disabled Americans. To receive benefits, medical charges must meet Medicare standards, which normally include approval by a qualified physician. In order to be eligible, a Medicare-certified provider such as a hospital or other health care provider, who, like our facility, has been approved to participate in the program, must deliver services. Below is a very brief description of Medicare benefits by health care setting.

Medicare Part A

Medicare Part A pays for a 90-day portion of inpatient hospital stays per benefit period. The patient is required to pay a deductible at the onset of the hospital stay and a co-pay during days 61-90.

In order for Medicare Part A to pay for skilled nursing facility care, the patient must have a medical necessity for skilled nursing care as well as a preceding hospital stay of at least 3 days, with a transfer to the nursing facility within 30 days of the hospital discharge. Medicare Part A covers 100 days of skilled nursing care per benefit period. The first 20 days are paid completely by Medicare. The next 80 days of continuous skilled nursing care require a patient co-pay. No Medicare benefits are provided after day 100 unless the patient starts another benefit period. Benefits may be discontinued by Medicare during a stay if a patient no longer needs skilled nursing care.

Medicare Part B

As an enrollee of Medicare Part A, the patient is automatically enrolled in Medicare Part B unless specified otherwise with the Social Security office. Unlike Medicare Part A, the patient must pay premiums to receive Part B coverage. Part B coverage is voluntary and the patient can choose to withdraw at any time.

As a participant in the Medicare Part B program, the patient is responsible for a $100 deductible each calendar year, as well as 20 percent of all approved charges beyond the deductible. Medicare Part B will pay the remaining 80 percent of the charges related to:

  1. Medical and surgical procedures the patient receives in a physician’s office, a hospital, a skilled nursing facility, or at home
  2. Diagnostic tests and procedures related to treatment
  3. The medical opinion of a second physician, when appropriate
  4. Services received in an emergency room or outpatient clinic
  5. Mental health care in a hospital or outpatient clinic
  6. Medically necessary ambulance transportation
  7. Durable Medical Equipment (e.g. oxygen equipment and wheelchairs)
  8. Other designated services

Medicaid

Medicaid is a state and federally funded program that provides payment for health-related services including those provided in a nursing facility. To qualify for Medicaid coverage a person must meet certain income, asset and medical criteria. Each state administers its own unique Medicaid program within certain federal guidelines. The services covered, as well as the eligibility requirements for nursing facility services with which each state program must comply, include, but are not limited to the following:

Eligibility Requirements

  • The patient must be 21 years of age or older, and a U.S. citizen or resident alien.
  • The patient must have a medical need for nursing facility services.
  • The patient’s monthly income and countable assets must not exceed the eligibility limits set by the state. The patient may retain his or her residence and may still qualify for Medicaid if he or she plans on returning to the residence, or if his or her spouse or a dependent person is residing there.

Medicaid coverage will continue as long as the patient continues to meet all of the eligibility requirements, including those identified above.

Our facility will assist with the entire Medicaid process.