The Medicare Program
Am I eligible for Medicare?
Medicare has four separate parts: Medicare Part A, which is hospital insurance; Medicare Part B, which is medical doctor insurance; Medicare Part C, which is Medicare Advantage (HMO); and Medicare Part D for prescription drugs.
Individuals are eligible for Medicare Part A hospital coverage provided they are: are eligible for Social Security or Railroad Retirement benefits and are over age sixty-five, who have paid FICA or SECA taxes through employment for at least 40 quarters; or, if they are not eligible for Social Security or Railroad Retirement benefits but who were employees of the federal government, they then must be over age sixty-five and have worked at least 40 quarters; or, Disabled, as determined under the Social Security Act, for at least 24 months (regardless of age); or, have end-stage renal disease or ALS regardless of age; or are over sixty-five but ineligible for Social Security benefits because of not having worked the requisite number of quarters, but elect to purchase Part A at a monthly premium.
Individuals are eligible for Part B coverage provided they are: eligible for Medicare Part A under any of the above methods; or are U.S. residents or lawful resident aliens who have resided here continuously for five years or longer and are over age sixty-five (regardless of employment history).
Does Medicare pay for Long Term Care Services?
Contrary to the belief of many seniors, one cannot rely on Medicare for payment of long-term care costs. Although Medicare is available to most individuals age 65 or older, coverage is limited to: qualified medical expenses (80% of an approved amount for doctors, surgical services, etc.); hospitalization for 90 days per benefit period with a deductible of $1,156.00 (total) for the first 60 days and a co-payment of $289.00 per day for the remaining 30 days, and an additional one-time, lifetime benefit of 60 days, with a co-payment of $578.00 per day (for a maximum of 150 days); and post-hospital skilled nursing home care with payment in full for 20 days and a co-payment of $144.50 per day for 80 days (maximum of 100 days).
Medicare only pays for nursing home care if the care provided is considered "skilled care", which is care provided under the supervision of a doctor requiring skilled professionals, as opposed to "custodial care", which provides basic personal care and other maintenance level services. Specifically, Medicare offers the following benefits:
Skilled Nursing Facility Care: Skilled nursing facility care is designed to provide care only for short term stays for an acute condition. Medicare does not provide any coverage for custodial care, which is the majority of nursing home care. Care that can be provided by non-medical professional is custodial. Medicare will provide limited coverage of a nursing home stay only if: (1) the patient was hospitalized for at least three consecutive days excluding the day of discharge, (2) admission to the nursing home is within thirty days of the hospital discharge, unless such care is medically inappropriate within that time, (3) the patient requires skilled nursing or skilled rehabilitation services or both, on a daily basis and such services can be provided only in a skilled nursing facility on an inpatient basis, (4) the services provided are for a condition that was treated while the patient was hospitalized, and (5) the patient’s stay is approved by the facility’s utilization review committee and the peer review organization.
Home Health Care: Limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy, and speech-language services that are ordered by one’s doctor and provided by a Medicare-certified home health agency. Also includes medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
For all Medicare benefits there are deductibles and co-payments, which can be substantial. There are excellent insurance policies available to fill these "gaps" in Medicare coverage, appropriately called "Medigap" insurance, which must be purchased privately. For more information, please request our Memorandum on Medicare Supplemental Coverage.
This Memorandum is based on current law and is for informational purposes only. It is important that you discuss all legal options and consequences with a qualified elder law attorney prior to any action. Should you wish to discuss your situation with us, please call (631) 424-2800 for a consultation. For additional Memoranda, please call or visit our website at www.elderlaw.pro.
