Medicare For Dummies. Patricia Barry
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Free.
Source: Centers for Medicare & Medicaid Services
Note: Services labeled “free” (meaning no co-pay or deductible required) assume that you go to a doctor who accepts Medicare’s payment in full.
Specialized care in certain circumstances
Medicare Part A is usually associated with care within the hospital, of course. But it also covers certain specialized services outside the hospital, most of which focus on nursing. Part B, too, covers some types of specialized care, such as physical therapy. The following sections provide a quick overview.
Care in a skilled nursing facility
Say you’ve been in the hospital and are being discharged but still need more-specialized nursing care than you can receive at home — physical therapy to help you walk again after a hip replacement, speech therapy after a stroke, a continuing need for intravenous fluids, or wound care. Medicare covers this type of ongoing care under Part A, usually at what’s called a skilled nursing facility — most often a nursing home — under certain conditions.
The most important condition for Medicare coverage of care in a skilled nursing facility is that you must have been in the hospital as a formally admitted patient for at least three days. (This three-day rule conceals a hidden pitfall — situations where the hospital places you under “observation” — that you really need to know about; see Chapter 14.) A doctor must order the services that you need from professionals such as registered nurses and qualified physical therapists and speech or hearing pathologists. And the skilled nursing facility you go to must be one that Medicare has approved.
Traditional Medicare covers stays in a skilled nursing facility for up to 100 days in a benefit period. The first 20 days cost you nothing; from day 21 through day 100, you pay a daily co-pay, which goes up slightly every year (in 2020, $176 a day). Some Medigap supplemental insurance policies cover these co-pays 100 percent. (Head to Chapter 4 for details about Medigap insurance.) If you’re enrolled in a Medicare Advantage health plan, look at your coverage documents or call your plan to find out what it charges for stays in skilled nursing facilities.
www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf.
Home health-care services
These services provide some of the same types of care that you may get in a skilled nursing facility but bring them to you in your own home. They include
Skilled nursing care provided on a part-time basis (no more than eight hours a day over a period of 21 days or less) and including services such as injections, feeding through a tube, and changing catheters and wound dressings.
Physical, speech, and occupational therapy from professional therapists to help you walk again, overcome problems in talking, or regain the ability to perform everyday tasks, such as feeding and dressing yourself — whichever your medical condition requires.
Help from home health aides in personal activities such as going to the bathroom, bathing, dressing, or preparing a light meal if these are necessary in relation to your illness or injury. (But if this personal care is the only kind of care you need, you don’t qualify for home health coverage.)
Medical supplies such as catheters and wound dressings.
Medical social services such as counseling for social or emotional concerns related to your illness or injury and help finding community resources if you need it.
Medicare covers all these services in full by paying a home health agency a single payment to provide for 60 days of care at a time. Home health care is a valuable benefit, but the rules for qualifying are pretty strict. To get Medicare coverage, you must meet all these conditions:
You must be homebound — that is, unable to leave home without considerable effort, unaided, or at all.
A doctor must certify that you need one or more of the professional services in the preceding list (skilled nursing, physical or occupational therapy, or speech pathology).
You must be under a plan of care established and regularly reviewed by a doctor.
The home health agency caring for you must be approved by Medicare.
If you qualify, the agency must provide all the services specified in the doctor’s plan of care for you. But if you need (or ask for) an item or service that Medicare doesn’t cover, the agency must tell you so in advance and explain what it would cost you. If you need medical equipment, such as a wheelchair or a walker, while receiving home health care, you may get it through the agency, but you pay the normal 20 percent co-pay (as explained later in this chapter) unless you have Medigap insurance that covers that cost.
www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
Hospice care
There may come a time when a treatment intended to cure a serious illness stops working effectively or is more than the patient can bear. Hospice care offers an alternative in the last days or months of life. It focuses not on trying to cure the disease but on providing as much comfort as possible — medical, social, emotional, and spiritual — during the time left.
Medicare began covering hospice care in 1983, and it’s one of the most generous benefits that the program provides — at little cost to terminally ill patients or their caregivers. Patients who choose hospice care are offered a full range of medical and support services, most often in their own homes. It also allows them to be cared for temporarily in an inpatient facility, such as a hospital or nursing home, if their regular caregivers need a break.
To qualify for the hospice benefit, you must meet all these conditions: