Medicare%20Basics

1
Medicare Basics

• Health insurance
• Covers ACUTE care needs
• Skilled care only
• Medicares definition of skilled
• Rehab recovery focus
• Must show progress
• Only for Short-term, skilled,
  recovery-based care

2
LTC Funding Sources

• Medicare 14
• Short-term, skilled care only
• Individuals/Families 23
• Medicaid (welfare) 45
• VA 3
• Other 4
• Private Insurance 11 (LTCi?)
• Centers for Medicare Medicaid Services, 2000

3
Skilled vs. Non-skilled

• Medicare only covers skilled care
• IVs, regular injections, tube feeding, physical
  therapy, speech therapy, continuous O2, close
  monitoring round-the-clock, etc.
• AND must show progress toward recovery.
• Daily (SNF)
• In acute and sub-acute facilities
• Intermediate, not daily (HHC)

4
Skilled vs. Non-skilled

• Medicare does NOT pay for non-skilled care
  (custodial care) ... unless it does ...
• Non-skilled services are only covered when
  received as part of an approved skilled care
  need
• ADLs in the SNF
• Bathing/dressing visit at home
• If no Medicare-approved skilled care, then NO
  benefits for custodial services.

5
Skilled Nursing Facility (SNF)

• Following 3-night inpatient hospitalization
• Enter SNF w/in 30 days for same reason
• THEN
• Days 1-20 covered 100
• Days 21-100 covered after co-payment
• 2004 109.50/day
• But only IF receiving daily skilled care

6
Home Health Care

• Not subject to prior-hospitalization
• Unlimited
• BUT
• Must need skilled care intermittent basis
• Must be homebound
• Under physicians care
• Separate custodial visits covered

7
Medicare Managed Care

• 1983
• Part A Hospitalization
• Prospective Payment System (PPS) based on
  Diagnosis Related Group (DRG)
• Within 18 months SNF admissions 40
• Great for SNFs HHC industry, but ...

8
That was then ...

• Prior to 1998
• Extensive abuse by providers extending skilled
  services beyond guidelines or classifying chronic
  custodial needs as skilled or rehabilitative
• Avg. covered SNF stay, 50 days
• But Medicare paid for my Aunt Bettys home care
  for nearly a year ...

9
That was then ...

• Between 1992 and 1997, Medicare
• HHC providers increased - 6,000 to 10,000
• HHC budget - 7-billion to 18-billion
• HHC visits - 125-million to 300-million
• The caregiving industry forced Medicare back to
  the basics
• Skilled care only ...

10
... this is now

• Substantial reform starting in 1998
• SNFs on a form of prospective payment
• Based on Resource Utilization Groups (RUG) ...
  Similar to the hospital DRG system
• Avg. Medicare-funded stay down to 14 - 21 days
• HHC agencies also on RUG flat fees

11
Medicare and LTC

• Medicare covers some care costs
• But only for
• Short-term, skilled, recovery-based needs
• Medicare does not cover non-skilled, custodial
  care
• Med-Sup plans only pick up Medicare-approved
  deductibles co-pays
• Medicare is NOT a payer for LONG-term care. (gt90
  days)

12
Major Medical (lt65)

• Major medical for working-age adults also only
  covers skilled care
• Look at exclusions
• Custodial care
• Most limit number of days of SNF and HHC even if
  skilled care needed
• This is why 50-year-olds should by LTCi!

13
Medicare and LTCi Plans

• Do not rely on Medicare to cover 90/100-day EP
• A few carriers may still coordinate with Medicare
  during the EP Medicare-paid days will not count
  without other paid, covered services
• Clients need to plan for LONG-term, CUSTODIAL
  care needs

14
Medicare Planning

• Initial eligibility _at_ 65 ... Even though full SS
  retirement age increasing
• Potential for mistakes if Medicare delayed
• Continued group coverage past 65 tricky
• Can only delay Part B enrollment if WORKING and
  covered by a LARGE group (20 ees) medical plan
• COBRA retiree coverage is 2ndary