Many times people have a great deal of confusion surrounding Medicare and what it may or may not cover. Often professionals will come across the same type of questions regarding this complex benefit. Below are several scenario style questions that are most commonly heard, along with the correct responses for each. These are offered as a guide to help understand your benefit.
True or False:
1. Medicare will pay for my nursing home care as long as I need it.
A: False: Medicare Part A only covers the necessary skilled need within a nursing home. Generally days 1-20, then from day 21, the person may need to pay a co-pay amount. It will cover only up to 100 skilled days in total, but a co pay will be needed after day 21. Also, it is not usual for a person to use Medicare within a nursing home past day 21. Very few people need skilled care for more than 21 days, although it is possible.
2. I am entitled to 100 days in nursing home, so I should get all 100 days.
A: True and False: While you may be eligible for 100 days under Medicare, it is your physical skilled need that determines the length of time, 100 days is not automatic. The nursing home staff, therapy staff, along with a person’s physician, will determine if a defined skilled need is present and coverable under Medicare Part A.
3. Just being in a nursing facility means I need skilled care.
A: False: Most people residing in a nursing facility or as it is sometimes referred to, a “skilled nursing facility” are not using Medicare benefits. Remember, Medicare is designed to help you recover form an acute illness or need, it is not designed to pay for routine or custodial care (daily care such as bathing dressing and grooming). Just needing 24 care does not mean you have a “skilled need”. Medicare does pay for you to live inside a nursing home past your skilled need.
4. What if I’m weak and need help with dressing and meals and bathing, those are skilled needs.
A: False: Think of a skilled need like this: After a joint surgery (e.g. a hip repair) or other acute episode, you may need a place to receive inpatient therapy or other nursing services on a limited basis to recover. Recovering does not mean regaining independence. You may recover from hip surgery and subsequent therapy, but still need help dressing, bathing or help with medications. Medicare covers only the time until skilled therapy is no longer required. If daily nursing home staff can assist you, that is not skilled and not covered.
5. Medicare will cover help in the home for as long as I need.
A: False: Medicare will cover Home Health for a skilled and usually temporary need. Again, Medicare is designed and intended to be used in short amounts to recover from an illness or medical need. It will not cover personal care attendants and assist in the home once the skilled reason is resolved.
6. Medicare will cover Assisted Living.
A: False: Medicare does not cover Assisted Living. Assisted Living is NOT a federal program, but managed by each state individually. Some State Medicaid programs may cover Assisted Living or congregate living.
7. If I signed up for an Advantage Plan (HMO or PPO) to manage my Medicare, I still have Traditional Medicare.
a. False: Medicare Part C or Advantage Plans, are third party contractors who have agreed to manage your Medicare benefits. By assigning your benefits to a third party, you no longer have original or traditional Medicare coverage. While third party contractors follow many of the same rules of traditional Medicare, they do not have to follow all of the traditional rules. Be advised when signing up for Advantage plans as to how they are managed and how your benefits will be managed and applied.