Salter Healthcare Services PO Bo

MEDICARE PART A - COVERAGE

Medicare Part A – The following are four basic requirements for Medicare Part A coverage in a SKILLED NURSING FACILITY.

The patient has Medicare Part A insurance
The SKILLED NURSING FACILITY accepts Medicare Part A
The patient is admitted to the SKILLED NURSING FACILITY within 30 days after a
hospital stay of at least three nights.
The patient requires skilled nursing services or therapy services that must be performed or supervised by professional or technical personnel, based on Medicare A program regulations.

Frequently Asked Questions:

How many days will the Medicare Part A insurance pay for in a skilled nursing facility if the four items listed above are met?

The Medicare Part A insurance will pay UP TO 100 DAYS if item 4 above is determined to be required for that length of time. However, it is common that the Medicare Part A insurance stops paying for services well before the 100 day maximum when custodial services are needed.

What is the difference between skilled and custodial services?

Skilled services are made up of two components that can be given together or separately. One of the components is therapy. Therapy consists of physical, occupational and speech. If the patient is receiving a combination of anyone of the therapies and showing improvement than in most cases it is considered skilled. The other component is nursing. If a patient requires a nursing service that can only be delivered by a professional nurse than in most cases it is a skilled service.

Custodial Services relate to bathing, grooming, dressing, feeding and other activities of daily living provided to the patient.

Who determines when the Medicare Part A insurance should end prior to the 100 day maximum time?

This decision is made by the professionals providing the services at the SKILLED NURSING FACILITY.

What is an example of why a patient would not qualify for Medicare Part A insurance prior to the 100 day maximum?

If a patient’s condition has improved to the point that services of a skilled professional such as a nurse or therapist are no longer needed, then in most cases the Medicare Part A insurance will stop paying for the stay at the SKILLED NURSING FACILITY. For example, if a patient suffered a fractured hip and with therapy reached their full therapeutic potential, required no skilled nursing services and yet remained in the nursing facility, Medicare Part A insurance would end on the last day of therapy.

MEDICARE PART A – FINANCIAL RESPONSIBILITY

When a patient’s stay is covered by Medicare Part A is the patient responsible to pay any money to the nursing home?

From day 1 to day 20 the patient does not have to pay anything to the nursing home.

From day 21 up until Medicare Part A coverage ends or the 100 day maximum is reached the patient will have to pay a co-payment to the nursing home.

The co-payment is $128.00 for calendar year 2008. This amount is set by the Federal Government and changes each January.

What happens if the patient has a co-insurance that will pay the co-payment?

In many cases the SKILLED NURSING FACILITY will take the co-insurance information and bill the company. However, each insurance plan is different and in many cases the insurance will not pay the full co-payment amount.

For example: for 2009

Co-insurance = $128.00

Co-insurance pays 80%

Patient is responsible to pay the nursing home $ 99.20 per day

It is important that the patient check with the SKILLED NURSING FACILITY to make sure the facility takes the patient’s HMO insurance. Not all SKILLED NURSING FACILITIES have contracts with all the HMO’s.

Most HMO’s require preadmission approval before the patient can be admitted to a SKILLED NURSING FACILITY. Once the patient is approved most HMO’s will stay in daily contact with the SKILLED NURSING FACILITY to monitor the patient’s progress. As some point the HMO Case Manager will inform the SKILLED NURSING FACILITY that the HMO insurance coverage will be ending. A notice will be given to the patient stating the last day of HMO coverage.

Most HMO’s that approve a skilled stay in a SKILLED NURSING FACILITY do not require the patient to pay the nursing home during the stay. However, once the HMO ends the coverage and if the patient remains in the SKILLED NURSING FACILITY, it will become the patient’s responsibility to pay the SKILLED NURSING FACILITY.

If a patient does not qualify for any type of insurance then the nursing home will bill the patient directly. The patient should be aware of the nursing homes daily private rate and the billing policy.

Medicaid is a program administered by the State for patients who are financially and medically eligible for nursing home services. Patients who are eligible for Medicaid will have a portion of their room and board paid by the Medicaid program.

The patient or someone designated by the patient must file a Medicaid application with the Division of Medical Assistance for the Commonwealth of Massachusetts in order to determine if you are eligible for Medicaid.

Is the patient automatically eligible for Medicaid once the application has been filed?

No. Medicaid uses a formula to determine if the patient is financially eligible. In addition the patient’s medical status is evaluated to determine if placement in the nursing home is clinically appropriate.

If the patient is eligible for Medicaid, is the patient responsible to pay any funds to the nursing home?

Yes. Medicaid requires by law, that the patient pay a portion of their monthly income to the nursing home less sixty dollars. The patient is allowed to keep sixty dollars for personal expenses each month. Usually the patient’s Social Security and any pension amounts added together less sixty dollars is amount Medicaid requires the patient to pay the nursing home.

The key to paying for nursing home care is understanding the different financial layers and when each layer applies.