elder-helper

Medicare and Medicaid

Medicare
I'm not quite sure where to begin. The subject of Medicare and Medicaid can be both confusing and a source of frustration for
both the consumer and the provider. Much has been talked about both in recent news, especially health care reform. People are
very passionate about this topic. Below you will find excellent publications from the Centers for Medicare and Medicaid
services. They answer almost every question you can think of regarding Medicare, your rights and benefits.
Sadly, Medicare reimbursement for the year 2010 is being reduced for providers despite increases in health care costs and of
course, the annual increase of inflation that impacts everyone. This will have an immediate and negative impact on our Nations
elderly. This is bad enough but are you familiar with the current status of Medicare? For example, traditional Medicare part A
pays for sub-acute rehab for nursing home stays. It covers just about everything for the first 20 days. Beginning on day 21, the
resident is required to pay a daily "co-pay" of $137.50 per day! (as of 2010). (Medicare Advantage programs are different and
have different co-pays based on the plan)
Let me share a typical scenario with you. Bob is 87 years old and falls at home and breaks his hip. He is hospitalized for surgical
repair of his hip and is sent to a nursing home for sub acute rehab. His anticipated length of stay is roughly 6 weeks due to
post-op anemia, worsening congestive heart failure and pain. Day 20 approaches and he realizes that he will be financially
responsible for a $133/day co-pay and he absolutely cannot afford it. He is living on Social Security only and has no money. The
problem is that his hip is not fully healed and he is physically unable to provide for his own care. He tells his doctor, "I'm going
home tomorrow, I don't care if I have to limp around my house or crawl to the bathroom, I can't afford $133 a day."
This sounds like a nightmare scenario and it is. I see it happen all the time. Some people have supplemental insurance or
Medi-gap insurance. Others have Medicaid which may help offset the co-pay. Some Medicare Advantage plans are even
worse. I have seen co-pays start on day 5 and range from $90/day to $133/day. I have also seen some plans with no co-pay. If
you are a senior and you are going to sign-up with Medicare, I highly recommend that you read the fine print, ESPECIALLY if
you are enrolling into a Medicare Advantage plan. The low monthly deductibles may seem appealing but you must read all the
details. You don't want to find out what your coverage is when you are in a nursing home or hospital.

Resources

The booklet "Medicare at a glance" published by CMS is a very brief, simple document that explains just the very basics of
Medicare. To download a copy, click here.

The booklet entitled "Medicare Coverage of Skilled Nursing Facility Care" is published by the department of Health and Human
services. It explains your Medicare coverage in skilled care, either in the hospital or in a nursing home; your rights and
protections; where you can get help with your questions. I found that it uses plain English and is written in easy to understand
format. It does a good job of explaining how and when you might re-qualify for Medicare after leaving a nursing home, when
your benefit period begins and ends, etc. Click here to download the booklet.

The publication "Medicare and you 2008" from CMS is much larger and more detailed. It provides actual cost figures and
details on Medicare A, B, C, D; your rights and responsibilities, private insurance, preventative services and much more. Click
this link to download.

Medicaid

Medicaid is a federally funded insurance program that is managed by individual states for people over the age of 65 or those
who are blind or disabled. There are asset and income limitations (but not for Medicare). If you have a spouse, their income and
assets may be also considered. You may have Medicare and Medicaid at the same time.
Medicare will not pay for custodial or basic care in a nursing home but Medicaid will if you need nursing care. If you are
completely independent with your own care, you may not qualify to live in a nursing home under Medicaid. Each state has
different standards on how a person qualifies for Medicaid and who may live in long-term care or not.
If you "spend down" your assets so that you may qualify for Medicaid, you should know that when you apply, the state agency
will look back to determine when and how you unloaded your assets. You could be denied Medicaid based on how and when
you spent down. I recommend that you consult an attorney who specializes in this area if you think you may be applying for
Medicaid in the next 5 years. For details on these rules, click here to see the social security administrations website on this
subject.