Frequently Asked Questions

Medicare

What is Medicare and what does it cover?

Medicare is a federal health insurance program (administered by the Centers for Medicare and Medicaid Services (CMS)) for people age 65 and over and certain disabled people under 65.

Medicare is divided into two parts:

Hospital Insurance - Part A:
Part A covers care provided by a skilled nursing facility to help a beneficiary recover from an acute illness or injury. Medicare provides full coverage for the first 20 days of care in an skilled nursing facility and a portion of the costs for skilled nursing facility care for days 21-100. During this period, the patient pays a daily coinsurance rate. Any Medicare A stay requires a 3-day hospital stay within 30 days of admission to a skilled nursing facility.

Medical Insurance - Part B:
Part B is a supplemental program for which you must pay an annual premium and a deductible for all covered services, including physician services.

Essentially, Part B coverage relates to ancillary services such as physician services, lab work, x-rays, and therapy. In some cases, Part B may cover short-term services - such as physical or other therapies - within an assisted living facility. After meeting the deductible, Part B pays 80 percent of the reasonable charges for covered services only. Part B may pay for covered services you receive from your doctor while in a skilled nursing facility from the time of admission.

What are the eligibility requirements for Medicare coverage in a nursing facility?
The nursing facility must be a skilled nursing facility that provides 24-hour nursing care to patients for recovery, rehabilitation and/or long-term care.

The individual must require skilled nursing care or rehabilitation services (as defined by the federal government) on a daily basis.

The patient must have spent three consecutive days in a hospital and the admission to the SNF must occur within 30 days of discharge from the hospital.

A physician must certify that the services required by the patient in a skilled nursing facility are needed for the same or related illness for which the person was hospitalized.

What services does Medicare Cover within a skilled nursing facility?

• A semi-private room
• Meals, including special diets
• Regular nursing services
• Rehabilitation services
• Medications furnished by the facility
• Medical supplies

What services are not covered by Medicare within a skilled nursing facility?|

• Personal convenience items
• Private duty nurses
• Extra charges for a private room, e.g., TV, phone, laundry, etc.

What services are not included under Medicare Part B?

• Routine foot care
• Eye or hearing exams for prescribing or fitting eyeglasses or hearing aids
• Immunizations other than for the flu or pneumonia

How do you apply for Medicare?
You can apply for Medicare Part A and B at your local Social Security office. The office can tell you whether you are automatically covered for Part A because of credits earned during past employment.

Medicaid

What does it cover?
For qualifying individuals, Medicaid pays for nursing facility services in a certified skilled or non-skilled facility. In many states, Medicaid will pay for assisted living services, although coverage is limited.

Who is eligible for Medicaid?
You must meet a state-determined poverty level and certain health criteria. Medicaid is also the primary payer of services for persons with Mental Retardation and Developmental Disabilities.

How do you apply for Medicaid?
Contact your local Department of Welfare or the Department of Health for an application. Because Medicaid is based on financial need, you will need to provide extensive information on your income, assets, and savings.

What if I am a Veteran?
The Department of Veteran's Affairs (VA) provides care in its own facilities to veterans in need of skilled or intermediate nursing care. The VA also provides both skilled and intermediate care to veterans through contracts with community nursing homes.

What does supplemental or long-term care insurance cover?
Insurance coverage is available to cover certain costs of nursing facility care. Some plans will supplement Medicare or Medicaid coverage and cover expenses beyond what these plans cover. Others pay for a portion of the daily expense for a set amount of days in a nursing facility.

If you or your family member has such insurance coverage, bring a copy of the policy to the attention of the nursing facility. You can then work with the administrative staff and discuss how they want to file claims to receive the best benefits.