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What Does Medicare Cover?

Medicare is a federally funded health insurance program for:

  • People 65 and older
  • Certain disabled people under 65

Generally, Medicare provides benefits for people who have, or are recovering from, an illness or injury. Medicare skilled-nursing community benefits are provided only for those purposes. Medicare is not a long-term care program.

How Medicare Works:

Medicare is divided into two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

About Part A - Part A pays for covered services received from hospitals and other institutional providers, such as skilled-nursing communities. Most people are entitled to Part A coverage (you have to have worked and paid Social Security taxes for at least 24 quarters). People who are entitled to Part A are automatically enrolled in it when they sign up for Social Security.

About Part B - Part B is an optional program. It covers primarily services from doctors and other professional healthcare providers. If you choose this coverage, you must pay a monthly premium. There is also a deductible for all Part B services, including doctor’s services. Then, Medicare pays 80 percent of the allowed amount for covered services. You pay 20 percent.

How Medicare Part A Nursing-Home Benefits Are Provided:

Medicare nursing-home benefits are provided under Part A, and these benefits are very limited. For each benefit period or “spell of illness,” Medicare will provide benefits for up to 100 days, as long as therapy or nursing care is required, of care in a skilled-nursing community, as follows:

  • Days 1-20: Medicare pays 100 percent.
  • Days 21-100: You pay a daily co-insurance; Medicare pays the rest. The co-insurance amount changes each year. In 2012, the amount you must pay is $144.50 a day. If you have a supplemental insurance, it may pick up some or all of this co-insurance.

Medicare only provides benefits under the following conditions:

  • Have Medicare Part A coverage
  • Have had a three-day hospital stay
  • Be admitted to the skilled-nursing community within 30 days of your hospital discharge
  • Require skilled services on a daily basis (That means seven days a week for skilled-nursing services or at least five days a week if your admission is for skilled-rehabilitation services only.)
  • Receive skilled treatment that is appropriate for the illness for which you were hospitalized—or a related illness—and is ordered by a physician in writing
  • Not have used up the 100 days of skilled-nursing care available per benefit period under Medicare (Or if you have already used up 100 days, you must have been out of a hospital or skilled-nursing community for 60 consecutive days before you start a new benefit period and are eligible for more skilled-nursing benefits.)

Covered Part A Services - Services covered in a skilled-nursing community include:

  • Meals, including special diets
  • Regular nursing services
  • Rehabilitation services
  • Drugs our community provides to you
  • Medical supplies

Services Not Covered - Medicare Part A doesn’t cover:

  • Personal convenience items
  • Private-duty nursing

How Medicare Part B Benefits Are Provided:

Medicare Part B doesn't have eligibility requirements like Part A does. (There is no “benefit period” limitation, for example, and no required hospital stay before benefits in a skilled-nursing community are available.)

Covered Part B Services - If you buy Part B coverage, it will pay toward covered doctor’s services while you’re in a skilled-nursing community. But remember, you have an annual deductible, and then you pay 20 percent.

Part B may also pay toward rehabilitation therapy services (services of a physical therapist, speech therapist, etc.) if you have used up your Part A coverage for a spell of illness. In other words, if you have used up your 100 days of Part A skilled-nursing coverage (which includes therapy services in the daily rate), but you still need to stay in our community, you would have to pay our charges yourself. But you could submit a claim to Medicare Part B for the therapy services and receive reimbursement for covered services.

Services Not Covered - Part B does not cover: Routine physical exams and tests -- routine foot care -- eye and hearing exams for prescribing or fitting eyeglasses or hearing aids --- immunizations, except for flu and pneumonia.