Patricia Carrera

Medicare pays for health care for:

• People age 65 years and older
• People under age 65 with receiving Social Security Disability benefits
• People of all ages diagnosed with Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) or end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).

Medicare covers medically necessary care for acute care, such as doctor visits, drugs, and hospital stays.

Except for the specific circumstances described below, Medicare does not pay for most long-term care services or personal care— such as help with bathing or for supervision (often referred to as custodial care).

When Does Medicare Pay for Long-term Care Services?

Following Hospitalization

Medicare will help pay for a short stay in a skilled nursing facility if you meet all of the following conditions:

• You have had a hospital admission with an inpatient stay of at least three days
• You are admitted to a Medicare-certified nursing facility within 30 daysof that inpatient hospital stay
• You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy

If you meet all these conditions, Original Medicare will pay a portion of the costs for up to 100 days for each benefit period as follows:

• For the first 20 days, Medicare pays 100 percent of the cost.
• For days 21 through 100, you pay a daily copayment, which was $164.50 as of November 2017), and Medicare pays any balance.
• Medicare does not pay costs for days you stay in a skilled nursing facility after day 100.

(Medicare Advantage plans must cover the same services, but the cost sharing may vary.)

To treat medical conditions

Medicare pays for the following services when your doctor prescribes them as medically necessary to treat an illness or injury:

• Part-time or intermittent skilled nursing care
• Physical therapy, occupational therapy, and speech-language pathology provided by a Medicare-certified home health agency.
• Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding your disease
• Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, Medicare pays 80 percent of approved amount and you pay 20 percent.

There is no limit on how long you can receive any of these services as long as they remain medically necessary and a doctor reorders them every 60 days. There also is no requirement for your condition to improve, or for improvement to be expected.

To prevent further decline due to medical conditions

In some cases, Medicare also covers ongoing long-term care services to prevent further decline for people with medical conditions that may not improve. This can include conditions like stroke, Parkinson’s disease, ALS, Multiple Sclerosis, or Alzheimer’s disease.

Hospice care

Medicare covers hospice care if you have a terminal illness, are no longer seeking a cure, and you are not expected to live more than six months. With hospice care, Medicare covers drugs to control symptoms of the illness and pain relief, medical and support services from a Medicare-approved hospice provider, limited respite care, and other services that Medicare does not otherwise cover, such as grief counseling. You may receive hospice care in your home, in a nursing home, or in a hospice care facility. Medicare also pays for some short-term hospital stays and inpatient care for caregiver respite.

Resources for additional Medicare information or help:

• medicare.gov to download or order the Medicare & You 2018 Handbook (PDF)
• 1-800-Medicare (1-800-633-4227) for specific billing and coverage questions
• State Health Insurance Assistance Program (SHIP) for personalized information and assistance, find state contact information at shiptacenter.org

Last modified on 02/18/2020
For more information – www.longtermcare.gov or www.acl.gov

Currently, Medicare beneficiaries who are not officially admitted to a hospital may be classified under “observation status,” which is treated as an outpatient procedure for billing purposes. Unfortunately, the common practice of placing a beneficiary on observation status can have significant financial consequences for Medicare beneficiaries since Medicare Part A and its related coverage rules only apply to actual inpatient care admissions. This may lead patients, many who are extremely sick and may need skilled nursing care, to spend many days in the hospital and be charged for services that Medicare would have otherwise paid had they been admitted. Furthermore, hospitals have up to one year to retroactively change admission status to observation, leading unsuspecting beneficiaries with thousands of dollars in bills for SNF care they believed would be covered by Medicare.

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Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare.  If you join a Medicare Advantage Plan, you still have Medicare.  These “bundled” plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare drug coverage (Part D).

Find Medicare Advantage Plans in your area.

Covered services in Medicare Advantage Plans

Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like some vision, hearing, dental, and fitness programs (like gym memberships or discounts). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.  Learn more about what Medicare Advantage Plans cover.

Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

• Whether you need a referral to see a specialist
• If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. In many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs. Some plans won’t cover services from providers outside the plan’s network and service area. 

Learn about these factors and how to get cost details.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

• Can’t offer drug coverage (like Medicare Medical Savings Account plans)
• Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

• You’re in a Medicare Advantage HMO or PPO.
• You join a separate Medicare Prescription Drug Plan.

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

Medigap policies can’t work with Medicare Advantage Plans. Learn about your options related to Medigap policies and Medicare Advantage Plans.
Click here for statistics – Click Here
For More Medicare information go to – Medicare.gov

The federal government has made important strides in reducing fraud, waste and improper payments across the government. The Affordable Care Act provided additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand its efforts to prevent fraud, waste and improper payments. The same innovative tools are being used to further enhance collaboration with our State and law enforcement partners in detecting and preventing fraud.

Using tools provided under the ACA, CMS has used a multifaceted approach, ranging from provider screening to the use of predictive modeling technology similar to that used by credit card companies that has saved nearly $60 billion during 2013-15. This equates to an average savings of $12.40 for each dollar spent on these program integrity efforts.

Guard Your Card Campaign

The CMS “Guard Your Card” campaign tells people how they can protect themselves against fraud by:

• Never giving out their Medicare or Social Security Number to anyone except those you know should have it.
• Reporting any suspicious activities like being asked over the phone for their Medicare/Social Security number or banking information. Medicare will NEVER call you uninvited for this information.
• By checking their billing statements and reporting suspicious charges. Using a calendar to track doctor’s appointments and services helps quickly spot possible fraud and billing mistakes. Check claims early by logging into mymedicare.gov.

Please report suspicious activities by calling 1-800-MEDICARE (1-800-633-4227).

Help Prevent Fraud – Click Here
The 4Rs on Fighting Fraud – Click Here

What is Extra Help with Medicare prescription drug plan costs? Anyone who has Medicare can get Medicare prescription drug coverage. Some people with limited resources and income also may be able to get Extra Help with the costs — monthly premiums, annual deductibles, and prescription co-payments — related to a Medicare prescription drug plan.

Click here for more details.