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Monday, January 20, 2014

Medicare vs. Medicaid: Similarities and Differences

Medicare vs. Medicaid: Similarities and Differences

With such similar sounding names, many Americans mistake Medicare and Medicaid programs for one another, or presume the programs are as similar as their names. While both are government-run programs, there are many important differences. Medicare provides senior citizens, the disabled and the blind with medical benefits. Medicaid, on the other hand, provides healthcare benefits for those with little to no income.

Overview of Medicare
Medicare is a public health insurance program for Americans who are 65 or older. The program does not cover long-term care, but can cover payments for certain rehabilitation treatments. For example, if a Medicare patient is admitted to a hospital for at least three days and is subsequently admitted to a skilled nursing facility, Medicare may cover some of those payments. However, Medicare payments for such care and treatment will cease after 100 days.

In summary:

  • Medicare provides health insurance for those aged 65 and older
  • Medicare is regulated under federal law, and is applied uniformly throughout the United States
  • Medicare pays for up to 100 days of care in a skilled nursing facility
  • Medicare pays for hospital care and medically necessary treatments and services
  • Medicare does not pay for long-term care
  • To be eligible for Medicare, you generally must have paid into the system

Overview of Medicaid
Medicaid is a state-run program, funded by both the federal and state governments. Because Medicaid is administered by the state, the requirements and procedures vary across state lines and you must look to the law in your area for specific eligibility rules. The federal government issues Medicaid guidelines, but each state gets to determine how the guidelines will be implemented.

In summary:

  • Medicaid is a health care program based on financial need
  • Medicaid is regulated under state law, which varies from state to state
  • Medicaid will cover long-term care
     

Monday, December 17, 2012

Changes to the Medicare Improvement Standard

For years, seniors with long-term conditions and age-related frailty who have needed rehabilitation care in nursing homes have been denied Medicare coverage for their care based on an “improvement standard.”


Read more . . .


Monday, August 06, 2012

Can You Get Good Care in a "Medicaid Nursing Home"

Betty was concerned and unsure about what to do next. Betty’s husband Ted, age 81, suffered his third stroke within the last two years and then he was hospitalized for a week. Ted was discharged to a nursing home for skilled rehab, but due to the effects of the stroke along with his dementia, he did not participate in rehab.


Read more . . .


Sunday, July 22, 2012

Medicare Coverage Issues in the Nursing Home

Whether Medicare will pay for skilled nursing facility services depends upon if the patient needs a “skilled level of care” on a daily basis. Generally, a skilled level of care is defined to mean the patient needs and will benefit from physical therapy, speech therapy and other such rehab. services that will restore or improve their health. Many patients also need custodial care in addition to such daily skilled care/rehab.


Read more . . .


Wednesday, July 18, 2012

Medicare Part A's Nursing Home Coverage

Medicare Part A will pay for part of up to 100 days of skilled nursing care per spell of illness in a nursing home or inpatient rehabilitation center.  In addition to meeting the basic eligibility requirements for Medicare detailed in the earlier posts in this series, there are three other requirements that must be met in order to receive this nursing home coverage under Medicare:


Read more . . .


Sunday, July 15, 2012

Hospital Discharge Issues

When an elderly person is admitted to the hospital, it’s a stressful event.  A situation that can compound that stress is if the hospital wants to discharge your older parent or other loved one before you feel they are ready to be discharged.


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Wednesday, July 11, 2012

Medicare Part A

Medicare Part A provides health care coverage for care in hospitals as well skilled care in nursing home or rehabilitation centers. Medicare Part A also provides coverage for care provided in hospice facilities and certain home health care services.


Read more . . .


Sunday, July 08, 2012

Medicare

After practicing elder law for 15 years, I have found that my prospective clients and their families continue to be mystified by the Medicare program and what it does and does not cover.  As such, this is the first in a series of blog posts that I hope will be useful in explaining the Medicare program.

Medicare was first enacted into law in 1965 and it is the United States government's health care insurance program for people 65 years of age and over. In addition, the program includes coverage for individuals who are permanently disabled, regardless of their age.  Unlike Medicaid, Medicare is wholly a federal program, meaning that the states are not involved in its administration.

Medicare is an entitlement program, meaning it is not based on financial need.  Even though Medicare is an entitlement, older people who have Medicare coverage still will have health care costs they may need to pay themselves.  For instance, there is a monthly premium for Medicare’s coverage.  In addition, Medicare recipients may also have to pay for a portion of the costs of the health care services they receive in the form of deductibles or co-insurance amounts.  Many seniors purchase supplemental health insurance, or have it as a retirement benefit through their former employer, that may cover all or part of these deductibles and co-insurance amounts.  These supplemental health insurance policies are often referred to as “Medigap” policies.

There are some medical services and items that Medicare does not cover, which will be detailed in later blog posts.  Two important ones are long-term nursing home care and in-home care.  Medicare mainly pays for acute care, which are medical services necessary to treat or diagnosis an injury or illness.  This means that the program’s coverage does not include many preventive health care services.

Medicare has four different parts:  Medicare part A includes hospital coverage.  Medicare part B coverage includes outpatient care, including doctor office visits.  Medicare part C, which was intended to provide additional options for health care services.  Medicare part D includes prescription drug coverage.

Eligibility Requirements

The eligibility requirements for Medicare part A are:

  • You must be a United States resident who is age 65 or older and you must be eligible for Social Security.  If you are not a U.S. citizen, you must be a legally admitted alien who has resided in the U.S. continuously for at least five years; or
  • If you have not attained age 65, you must be a disabled person of any age who has been entitled to Social Security disability benefits for 25 months; or
  • individuals who have end-stage renal disease will be eligible for Medicare Part A.

One is eligible for Medicare part B if they are age 65 or older, regardless of Social Security eligibility.

My next post will discuss in more detail the coverage provided under Medicare Part A.


Thursday, November 03, 2011

What’s the difference between a nursing home and assisted living facility?

As an elder law attorney practicing in Oakland County, I am often asked “what’s the difference between a nursing home and assisted living facility?”  The difference in the appearance between the two types of facilities can be dramatic, because nursing homes tend to be more hospital like. 

A nursing home provides residents with a room, personal care, nursing care, medical services, and meals.  As to the room, it is often semi-private, meaning the resident has a roommate.  Residents of nursing homes tend to have chronic conditions requiring long-term care and need assistance with multiple activities of daily living, such as bathing, dressing, eating, toileting, transferring in and out of beds or chairs, and help with continence issues.  Moreover, residents of nursing homes often have cognitive and memory problems due to various forms of dementia, such as Alzheimer’s disease.  Medicare does not pay for this long-term custodial care in a nursing home, but Medicaid will pay for nursing home care provided that the asset, income, and medical criteria are met.

Nursing homes also provide care for patients needing shorter-term recovery after a hospitalization.  Medicare may pay for up to 100 days of this type of skilled nursing care per spell of illness, which tends to be physical therapy and rehabilitation services after a stroke or broken bone.

The average cost of a nursing home in Michigan in 2011 is $220 per day, $6,692 per month, or $80,300 per year.

Assisted living residences provide services for people who are not able to live independently, but who do not require the level of care provided in a nursing home.  For instance, assisted living facilities provide housing for those who need help with day-to-day living, but who do not need the 24-hour level of care found in nursing homes.  Residents of assisted living may need help with personal care, assistance with meal preparation, some assistance with some of the activities of daily living, and housekeeping services.  Residents of assisted living facilities tend to have their own private living space, which can range from just a bedroom with a private bathroom, to a small apartment with a living room, bedroom, bathroom, and small kitchen area.  Assisted living facilities tend to have many activities for their residents.  Sometimes they seem like a nice resort with good staff and lots of activities.

Many assisted living facilities have special “memory units” for older people with Alzheimer’s and other forms of dementia who need a great deal of supervision. 

The average cost for assisted living in Michigan is $3,425 per month or $41,100 per year.  However, costs can easily exceed $5,000 a month for assisted living residents living in memory units.  Assisted living facilities in Michigan do not accept Medicare or Medicaid as a payment source for the cost of room and board.

In conclusion, nursing homes tend to be more institutional and hospital like.  They accept Medicaid as a payment source.  Some of the residents tend to be very frail, many others have dementia, and some residents of nursing homes are there because they have inadequate financial resources to live in assisted living or elsewhere.  Assisted living facilities are more home-like, though they can provide a similar level of care as a nursing home.  Assisted living facilities are strictly private pay, meaning the resident or family has to pay the bill out of their own funds or with long-term care insurance or the veteran’s Aid and Attendance benefit.


Wednesday, June 08, 2011

Medicaid Part 4 - What About Medicare?

In considering how to pay for nursing home care in Michigan, one of the first issues that comes up is if Medicare pays for nursing home care.  There is a great deal of confusion about Medicare and Medicaid, probably in part due to their very similar names.

Medicare is the federally funded health insurance program primarily designed for people age 65 and older.  It is national health insurance for everyone over age 65 and has been in place since the 1960’s. There are some limited long term care benefits that can be available under Medicare. In general, if you are enrolled in the traditional Medicare plan, and you’ve had a hospital stay of at least three days, and then you are admitted into a skilled nursing facility (often for rehabilitation or skilled nursing care), Medicare may pay for awhile.

Since it is national health insurance for those over age 65, there are no income or asset qualification rules for Medicare benefits in a nursing home, unlike Medicaid.  With Medicare nursing home benefits, the issue centers more on the type of care you need, not your assets or income.  If the patient broke their hip and needs physical therapy or had a minor stroke and needs rehabilitation services, Medicare may pay for those services in a nursing home for a period of time.  If an older person has dementia and it has been recommended that they need twenty-four hour custodial care in a nursing home or assisted living facility, Medicare does not pay for any of that care.

If you qualify, Medicare may pay for the full cost of the nursing home stay for the first 20 days and can continue to pay the cost of the nursing home stay for the next 80 days, but with a deductible that’s $141.50 per day. Some Medicare supplemental insurance policies, called Medigap polices) will pay the cost of that deductible. So, in the best case scenario, Medicare may pay for up to 100 days of skilled care or rehab. services for each “spell of illness.” In order to qualify for these 100 days of coverage, however, the nursing home resident must be receiving daily “skilled care” and generally must continue to “improve.” (Note: Once the Medicare beneficiary has not received a Medicare coverage level of care for 60 consecutive days, the beneficiary may again be eligible for the 100 days of skilled nursing coverage for the next spell of illness.)

While it’s never possible to predict at the outset how long Medicare will cover the rehabilitation in the nursing home, from my experience, it usually falls far short of the 100 day maximum. If the nursing home resident will not benefit from therapy or skilled care and just needs to live in a nursing home for the custodial care, Medicare will pay nothing. Even if Medicare does cover the 100 day period, what then? What happens after the 100 days of coverage have been used?

At that point, in either case you’re back to one of the other alternatives: long term care insurance, paying the bills with your own assets, or qualifying for Medicaid.

If an older person is receiving skilled care or rehabilitation services in a nursing home that is being paid for by Medicare and if it is unclear if they will be able to return home, that is a good time to meet with an elder law attorney.  The reason for this is that while Medicare is paying the nursing home bill, the spouse or family of the individual in the nursing home will have time to consult with the elder law attorney and consider and implement any Medicaid planning options, which may be appropriate.  Many families wait to contact an elder law attorney until after Medicare benefits have ended and they have been asked to pay a $6,500 deposit to the nursing home or are being billed $220 a day.  At $220 a day in Oakland County and as is common in other areas of southeast Michigan, after just one week, the nursing home bill will be $1,540.00.  Then a family can be in a crisis situation and may feel rushed to obtain information and make decisions while a large nursing home bill is being racked up.  By consulting with an elder law attorney earlier in the process, this stress can be avoided, better care decisions can be made, mistakes can be avoided, and more money can be saved.

Andrew Byers is an Elder Law Attorney in the Rochester Hills area and helps older people and their families make decisions about long-term care and asset protection.


Thursday, May 26, 2011

Medicare's Limited Nursing Home Coverage

Many people believe that Medicare covers nursing home stays. In fact Medicare's coverage of nursing home care is quite limited. Medicare covers up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered. The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.

In order for a nursing home stay to be covered by Medicare, you must enter a Medicare-approved "skilled nursing facility" or nursing home within 30 days of a hospital stay that lasted at least three days. The care in the nursing home must be for the same condition as the hospital stay. In addition, you must need "skilled care." This means a physician must order the treatment and the treatment must be provided daily by a registered nurse, physical therapist, or licensed practical nurse. Finally, Medicare only covers "acute" care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing.

Note that if you need skilled nursing care to maintain your status (or to slow deterioration), then the care should be provided and is covered by Medicare. In addition, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient's care and status. In such cases, Medicare should continue to provide coverage.

Once you are in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($141.50 a day in 2011). This copayment may be covered by a Medigap policy. After 100 days are up, you are responsible for all costs.


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