Understanding Medicare

Understanding Medicare.

I want to take a few moments to give the high-level overview of Medicare.

Surprisingly, few people really understand this program and what it covers and what options you have and don't have.

Additionally, people don't really take the time to review their options after enrolling if you are ill or health care coverage is the most important financial piece in keeping you on your treatment plan.

Medicare is a health care system founded and funded by the government on behalf of Americans that are 65 years old or older.

Your initial enrollment period starts up to three months before you turn 65.

If you want the coverage to begin effective on your 65th birthday, you will then have the month of your birthday and an additional three months after your birthday to sign up.

If you do not sign up during this time, you will have to wait until the next enrollment period, which lasts from January 1st to March 31st.

Then you would have to wait until July 1st for your coverage to begin.

There are different parts to Medicare because Medicare is a government-funded insurance.

Seniors have few options when signing up.

You can either sign up for traditional Medicare, which is Medicare Part A and B, or you can sign up for Medicare Advantage or Medicare Part C.

The prescription drug program is Medicare Part D. Medicare Part A is your traditional hospital and home health care insurance.

It covers services related to doctor's visits, ambulance services, and mental health services, among others.

Many also believe it is for nursing home care. We will talk more on this a little later on.

If you sign up for Medicare Part A and B, you can go to any hospital in the country that accepts Medicare patients.

Keep in mind there is no monthly premium for Medicare Part A, but there is a monthly premium for Medicare Part B.

Currently, that cost is $134 per month.

Medicare Part B covers two types of services: medically necessary services or services that supplies and supplies that are needed to diagnose or treat your medical condition.

Preventive services, health care to prevent illness or detect it at an early stage, you pay nothing for most preventative services.

If you get the help from a health care provider who accepts assignment.

Part B covers things like getting a second opinion before surgery, limited outpatient prescription drugs, clinical research, ambulance service, durable medical equipment, mental health, inpatient, outpatient, and partial hospitalization.

Medicare Part C or Medicare Advantage are private insurance programs administered by health insurance companies.

These plans must offer the same coverage as traditional Medicare plans, except for the hospital coverage, which is covered under the traditional Medicare Part A program.

However, Medicare Part C must also cover additional services and coverages that are not covered in traditional Medicare.

Unfortunately, this coverage is restrictive in that it does not allow you to visit any doctor you want.

Does Medicare pay for nursing home cost or long-term care needs?

Medicare does provide limited nursing home coverage.

Medicare Part A covers institutional care in hospitals and skilled nursing facilities, as well as certain caregiving by home health agencies and care provided in hospice.

Medicare Part A will cover up to 100 days of skilled nursing care per incident of illness.

However, guidelines must be met and they are quite stringent.

The recipient must have entered the nursing home no more than 30 days after a hospital stay for which they received treatment, and must have been at the hospital for at least three days and not including the day of discharge.

The care they receive in the nursing facility must be for the condition that calls for hospitalization or for a condition related to the hospital stay.

The patient must receive skilled level care in this nursing facility that cannot be provided at home or on an outpatient basis.

Skilled means the nursing home must be ordered by a physician and delivered by or under the supervision of a professional, such as a physical therapist, registered nurse, or a licensed practical nurse.

The care must also be delivered daily.

As soon as determined by the nursing home, that the patient is no longer meets the requirements of needing skilled daily care.

The Medicare coverage ends beginning the 21st day of the nursing home stay.

There is a significant copayment equal to one eighth of the initial hospital deductible of $170.50.

This deductible can usually be covered by a medigap insurance policy if the patient has one.

We will cover these supplemental policies a little later.

Medicare Part A will cover the patient again should there be a new visit to the hospital after 60 days of not receiving any skilled care in either a nursing home facility or in hospital.

It is unfortunate that nursing homes will often terminate Medicare coverage for skilled nursing facility care before they should, often for two reasons.

One, many nursing homes assume that if a patient has stopped making progress toward a recovery, the Medicare coverage should end.

They should understand instead that if the patient needs the skilled care in order to maintain his or her status, or to slow or prevent deterioration, then care should be provided and is covered by Medicare.

Many nursing homes falsely believe that the care in the facility must be given directly by a skilled nurse, and is therefore excluded from Medicare skilled nursing facility benefit.

In fact, care can be given while being supervised by a nurse and still be covered by Medicare skilled nursing facility benefit.

Additionally, a patient may need a wide variety of treatments that do not require a nurse to directly provide.

However, supervision by the nurse may be required to monitor the patient's care and status to prevent adverse interactions among the treatments.

Medicare, in this instance, will continue to provide coverage when a patient leaves the hospital and enters the nursing facility.

The nursing home will provide Medicare coverage.

The nursing home must give the patient written notice of whether the nursing home believes that the patient requires skilled nursing, at which point the Medicare is merited.

Unfortunately, even though the skilled nursing facility may initially treat the patient for several weeks, often the skilled nursing facility will determine the patient no longer requires skilled care and will issue a notice of non-coverage.

Terminating the Medicare coverage.

Even if the non-coverage determination is made prior to, or even after treatment at the skilled nursing facility.

The patient is offered a notice asking if they would like the bill to be submitted to the Medicare despite the nursing home's assessment of the patient's care needs.

The patient or their legal representative should always ask for the bill to be submitted.

This requires the facility to submit the patient's medical records for review to fiscal, Intermediary, an insurance company hired by Medicare, which reviews the facility's determinations.

This review is free of charge to the patient and may result in more Medicare coverage.

Also, while the case is in review, the patient is not responsible for the bill.

However, if after review appeal is denied, the patient must then pay the facility retroactively for the period under review.

If the intermediary agrees with the nursing home that the patient no longer requires skilled care, the next level of appeal is the administrative law judge.

Keep in mind, this appeal could take a year as well as a day to hire a lawyer.

This appeal should only be pursued if, after reviewing the patient's medical records, the lawyer believes that the patient was receiving a skilled level of care that should have been covered by Medicare.

If you get to this point and are still turned down, there are subsequent appeals to the Appeals Council in Washington and then to federal court in order to make sure you have chosen the best coverage for your unique situation.

It is best to talk to an expert that can go over your unique health situation.

Other credible coverage options you may have and the costs associated with each plan.

There are late fees or exclusions if some of your choices are not made in a timely manner.

You can get additional information from medicare.gov.

You can also get in touch with a local expert on Medicare.