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Medicare

Medicare only covers medically necessary care and focuses on medical acute care, such as doctor visits, drugs, and hospital stays. Medicare coverage also focuses on short-term services for conditions that are expected to improve, such as physical therapy to help you regain your function after a fall or stroke.  (In January of 2013 a lawsuit (Jimmo v. Sebelius) regarding the Medicare Improvement Standard was settled.  The Settlement may result in changes to this requirement.)

Eligibility

Medicare pays for health care for people age 65 years and older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).

Long-term Care Services – Skilled Nursing

Medicare does not pay the largest part of long-term care services or personal care—such as help with bathing, or for supervision often called custodial care. Medicare will help pay for a short stay in a skilled nursing facility, for hospice care, or for home health care if you meet the following conditions:

  • You have had a recent prior hospital stay of at least three days
  • You are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay
  • You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy

If you meet all these conditions, Medicare will pay for some of your costs for up to 100 days. For the first 20 days, Medicare pays 100 percent of your costs. For days 21 through 100, you pay your own expenses up to $140.00 per day (as of 2013), and Medicare pays any balance. You pay 100 percent of costs for each day you stay in a skilled nursing facility after day 100.

Long-term Care Services – Home and Other Care Services

In addition to skilled nursing facility services, Medicare pays for the following services for a limited time when your doctor says they are medically necessary to treat an illness or injury:

  • Part-time or intermittent skilled nursing care
  • Physical therapy, occupational therapy, and speech-language pathology that your doctor orders that a Medicare-certified home health agency provides for a limited number of days only
  • Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding your disease
  • Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, you pay 20 percent of the Medicare approved amount

There is no limit on how long you can receive any of these services as long as they remain medically necessary and your doctor reorders them every 60 days.

Hospice care

Medicare covers hospice care if you have a terminal illness and are not expected to live more than six months. If you qualify for hospice services, Medicare covers drugs to control symptoms of the illness and pain relief, medical and support services from a Medicare-approved hospice provider, and other services that Medicare does not otherwise cover, such as grief counseling. You may receive hospice care in your home, in a nursing home (if that is where you live), or in a hospice care facility. Medicare also pays for some short-term hospital stays and inpatient care for caregiver respite.

Download or order the consumer handbook Medicare & You 2013 to learn more about what Medicare does and does not cover.