Benefits Covered Under Part A of the Medicare Statutes
In general, Medicare is much like a health insurance policy. There are certain types of medical conditions covered, and certain limitations on coverage which will be paid by Medicare. If a condition exceeds the coverage limitation set forth in the Medicare "policy," you are required to pay the entire amount yourself, through your other insurance, or with your own assets.
Under this coverage, charges made to Medicare for you are submitted by the physician, hospital or other healthcare entity or provider. You are generally not responsible for submitting claims, as you would expect to under normal health insurance. Healthcare providers of any type are not permitted to make any charges to you for submission of these claims, and to do so is a violation of federal law.
Medicare covers each hospital benefit for up to 90 days in the hospital. However, Medicare does not pay for the 90 days in full. Instead, you pay a lump sum deductible for the first 60 days of your stay in the hospital. You pay an additional daily deductible amount for days 61 - 90.
While each hospital stay is limited to 90 days, there is no limit to the number of hospital stays which Medicare will cover, so long as you remain out of the hospital for 60 consecutive days from the date of last release from the hospital and the date of the next admission.
There is also a "one-time benefit" that Medicare will pay for a 60-day extension of a 90 day hospital visit. There is, however, a charge fixed by law which you are required to pay on a daily basis.
Nursing Care Benefits
When they turn 65, many people are more concerned about needing and paying for nursing care than a hospital stay. Medicare does provide some relief in this area. Medicare will pay for up to 100 days per benefit period for "skilled" nursing care services or rehabilitation services in a nursing home. You should be certain that all of the care, nurses and facilities are on Medicare's approved list, in advance of your admission, or use, since this will help to prevent disputes with Medicare over coverage issues later. For example, hiring a trainer three times a week at your health club to rehabilitate your severely sprained ankle may help your rehabilitation, but it will likely not pass muster with the folks at Medicare.
There are certain limits on the amount of care that is covered, and the amount of services which will be paid by Medicare in this area. Generally, the first 20 days of care are covered by Medicare with no payment by you. Thereafter, a daily deductible is paid by the person receiving the services and care for days 21 - 100.
The services and care covered are defined by the federal rules and regulations governing Medicare. In addition, certain coverages may vary by state, and of course, are subject to change. Covered services in this area generally include registered nurses, physical, speech and vocational therapy, medications, medical devices, medical treatment and medical supplies and equipment. If you have a question regarding whether a particular person's services are covered, it would be wise to seek counsel from a lawyer or assistance from Medicare, before incurring the costs of 100 days of treatment.
The nursing home aspect of Medicare coverage also has certain other requirements in order to be covered. First, the nursing home coverage must fit the definition of "skilled nursing care" as set forth in the appropriate regulations and laws. Second, prior to any nursing care being covered, the patient must have been confined to a hospital for 3 days at the minimum. Third, the nursing home must be entered within 30 days of leaving the hospital. Finally, there is a requirement that you be treated in the nursing home for the same condition for which you were treated in the hospital.
At Home Nursing Care or Other Assistance
Medicare imposes strict limits in this area, since it is an area which may have great potential for abuse. Unfortunately, it is the area that, with careful scrutiny, could help the patient the most for the least cost. Currently, Medicare is limited to coverage for nursing care, physical, speech and vocational therapy, and certain home health aides. Again, all of the nuances of the various regulations, federal and state, are beyond the scope of this discussion, and are subject to change each year.
However, as an overview, there are certain requirements which must be met to provide At-Home Nursing Care covered by Medicare. First, the patient must be "homebound," which means that the patient requires assistance to leave the house. Second, the patient must need some type of "skilled nursing care" at least once a day for the covered period, which is defined as at least 60 days. Third, the patient must be under the treatment of a "Plan of Care" prescribed by a physician, and the agency providing the At-Home Nursing Care must be a licensed and certified Medicare provider.
If these requirements are met, Medicare will pay for up to 35 hours per week of such care. In addition, other items covered include medical equipment and such related expenses. Medical equipment must be prescribed by a physician. The section on Durable Medical Equipment more fully explains this coverage.
It should be understood that Medicare coverage will not extend to certain functions which are some of the most necessary to patients who may have trouble leaving the house. That means that cooking, cleaning, laundry, bathing, toiletries and related necessities are not covered by Medicare, nor is coverage contemplated under Medicare.
Durable Medical Equipment Defined
Medical equipment is defined under the code as "durable medical equipment" and generally connotes medically-related equipment that meets the following elements:
- The equipment can be again used by others after your usage;
- The equipment serves a medical purpose;
- The equipment is useful for the illness from which the patient suffers; and
- The equipment can be used in the home by the patient.
Should there be an issue over whether your medical treatment will be covered, you should seek assistance from your Medicare office to make the determination of coverage in advance. Fortunately, very little of these expenses are "emergency" in nature, and as such, the time to make the determination of coverage is prior to making these expenditures.