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Long Term Care Resources |
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MedicareThe benefits described in these pages apply to a post-hospital Long Term Care ( i.e. Skilled Nursing Facilities ). While part of the same federal program, Medicare coverage for Hospital In-patient stays has a very different benefit and co-pay (deductable) structure. Medicare is a federal health insurance program for people 65 or older, people of any age with permanent kidney failure (ESRD), and certain disabled people under 65. The program is administered by the Centers for Medicare & Medicaid Services (CMS) — formerly known as HFCA — a department under the direction of the U.S. Department of Health and Human Services (HHS). The Social Security Administration, also a part of HHS, provides information about the program and handles enrollment. To locate a Social Security office near you if or need assistance with a question/problem, you may call toll-free Medicare Has Three Distinct Benefits: (for our purposes) Medicare-Part A is an "entitlement" program and is premium-free. You are automatically eligible to receive Medicare A after meeting certain requirements - you can not be denied Medicare A coverage once you meet the requirements. Medicare-Part B however, is an optional program and is offered to all beneficiaries when they become eligible for Part A. It also may be purchased by most persons age 65 or over who do not qualify for Part A coverage. Benefit Periods Coverage for care in hospitals and skilled nursing facilities is measured in "benefit periods." In each benefit period, you are limited as to the number of days Medicare will help pay for inpatient hospital and skilled nursing facility care. Once you exceed the limit, you are responsible for all charges for each additional day of care. A benefit period begins the day you are admitted to a hospital. It ends when you have been out of a hospital or skilled nursing facility for 60 straight days, including the day of discharge. It also ends if you stay in a skilled nursing facility, without receiving skilled nursing care for 60 straight days. Once you have ended one benefit period, a new benefit period begins and your hospital and skilled nursing facility benefits are renewed. There is no limit to the number of benefit periods you can have. The Medicare Part A "benefit period" contains 100 days. Patients must meet Medicare's strict skilled care requirements for each day to continue receiving benefits. If the requirements are not met, benefits will cease regardless of the number of days left in the benefit period. Medicare Part A - Hospital Insurance ( Includes Skilled Nursing Home Care ) Covers skilled nursing home care for a limited time period if ALL of the following requirements are met: 1. The patient requires one or more of the following skilled services "daily":
2. The patient has been in the hospital for at least three consecutive days, not including day of discharge. 3. The patient is admitted to a skilled nursing facility within 30 days after being discharged from the hospital- 4. The doctor certifies that the patient needs skilled care. Medicare Part A - Pays For:
Medicare Part A - Does NOT Pay For:
How Does Medicare Pay? Nursing Home Stay Must Require "Skilled" Nursing Care — "Custodial" Care Does NOT Qualify Nursing Home Inpatient Days 1 - 20:
Nursing Home Inpatient Days 21 - 100:
A Word Of Caution A portion or all of your 20 days of 100% coverage may have been used while in the hospital if you were transferred to a skilled nursing unit ( "swing bed" ) located in the hospital. Day 21, and the $124 a day co-pay, may begin immediately upon your admission to the skilled nursing home facility. It is important that you work closely with the hospital's social services department and/or discharge planners. If transfer to a skilled care nursing home is planned, contact the Admissions Coordinator at the receiving facility as early as possible prior to discharge from the hospital. The Admissions Coordinator can be a real asset and a guide through this maze. Your representative/family member will be asked to meet with the Admissions Coordinator to begin the admissions process. Some of the items the admitting facility may require include a copy of your social security card/Medicare card, powers-of-attorney for healthcare, finance, and advance directives, if any. Working closely with the admitting facility prior to the day of discharge will ensure a smooth transition and reduce some of the stress. Medicare — Approved Prescription Drug Discount Card Program On December 8, 2003, President George W. Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003. This act will immediately provide Medicare beneficiaries with discounts on their prescription drugs as well as provide comprehensive Medicare prescription drug coverage effective January 1, 2006. Starting in the Spring of 2004, as an important first step towards comprehensive Medicare prescription drug coverage, Medicare beneficiaries will be able to enroll in a Medicare-approved discount card program ( The Discount Card ) that will offer discounts on their prescription drugs. If your Medicare patients raise questions about the Discount Card, you should suggest they visit www.medicare.gov and select "Prescription Drug and Other Assistance Programs" or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-800-486-2048.
NOTE: Information for potential Medicare Prescription Drug Discount Card sponsors can be found at http://www.cms.hhs.gov/discountdrugs/. Medicare Drug Benefit Calculator - Kaiser Family Foundation This calculator allows users to enter their prescription drug costs to determine what they would pay under the Medicare reform. Standard coverage under the current proposal includes an upfront deductible of $250, 25% cost sharing between $250 and $2,250 in drug expenses, no coverage after $2,250 until the beneficiary pays the next $2,850 in expenses ( reaching $3,600 in out of pocket costs at $5,100 in total drug expenses ), beyond which 5% cost sharing applies. Medicare - Hospice Benefit The goal of hospice is to care for you and your family, not to cure your illness. If you qualify for hospice care, you can get medical and support services, including nursing care, medical social services, doctor services, counseling, homemaker services, and other types of services. Depending on your condition, you may have hospice care in a hospice facility, hospital, or nursing home. Hospice care is covered under Medicare Part A ( Hospital Insurance ). You are eligible for Medicare hospice benefits when:
The care that the hospice gives you is meant to help you make the most of the last months of life by giving you comfort and relief from pain. The focus is on care, not cure. What will I have to pay for hospice care? Medicare pays the hospice for your care. You will have to pay:
How long can I receive hospice care? You can get hospice care as long as your doctor certifies that you are terminally ill and probably have less than six months to live. Even if you live longer than six months, you can get hospice care as long as your doctor recertifies that you are terminally ill. Hospice care is given in "periods of care". As a hospice patient, you can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period of care, your doctor must certify that you are terminally ill in order for you to continue getting hospice care. A period of care starts the day you begin to get hospice care. It ends when your 90 or 60-day period is up. If your doctor recertifies that you are terminally ill, your care continues through another period of care. As a hospice patient, why would I stop getting hospice care? Sometimes a terminally ill patient's health improves or their illness goes into remission. If that happens, your doctor may feel that you no longer need hospice care and will not recertify you at that time. Also, as a hospice patient you always have the right to stop getting hospice care, for whatever reason. If you stop your hospice care, you will get your health care from your Medicare health plan, ( like the original Medicare Plan or a Medicare Managed Care Plan ). If you are eligible, you can go back to hospice care at any time. As a hospice patient, you always have the right to stop getting hospice care and go back to your regular doctor or health plan. How can I find a hospice program? To find a hospice program, call your State Hospice Organization. To get the most updated phone numbers, call 1-800-MEDICARE The hospice you choose must be Medicare-approved in order to get Medicare payment. To find out if a hospice program is Medicare-approved, ask your doctor, the hospice program, your State Hospice Organization, or your State Health Department. Can I change the hospice provider I get care from? As a hospice patient, you have the right to change hospice providers only once during each period of care. Resource Material Centers for Medicare & Medicaid Services Medicare Interactive -AARP Site Hospice Resources American Board of Hospice and Palliative Medicine, The Center to Advance Palliative Care Hospice Association of America, The Hospice Patients Alliance National Hospice & Palliative Care Organization Promoting Excellence in End-of-Life Care |
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