Medicare is a federal health insurance program for people over 65 and certain disabled people under 65. It is not a long term care program. Rather, Medicare covers only those nursing facility services rendered to help a beneficiary recover from an acute illness or injury. Medicare is administered by the federal government's Center for Medicare and Medicaid and is divided into two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). Payments are made to providers through private insurance companies with which the government contracts or through HMOs who have risk contracts with Medicare. Eligibility--Nursing facility coverage falls under "Part A" of Medicare and is very limited. Medicare pays up to a total of 100 days of care in a skilled nursing facility (SNF). Medicare will cover 100 percent of the first 20 days in a SNF; for days 21-100, the individual must make a daily coinsurance payment.
Medicare pays for nursing facility care only under the following conditions:
- The nursing facility is a skilled nursing facility (SNF). SNFs provide 24-hour nursing care to convalescent patients.
- Continuous skilled nursing care or skilled rehabilitation services (as defined by the federal government) are required on a daily basis.
- The patient has spent at least three consecutive days in a hospital and if the admission to the SNF occurs within 30 days after discharge from the hospital.
- A physician certifies that SNF services are needed for the same or related illness for which the person was hospitalized.
Benefits - If all of the above conditions are met, Medicare pays for the cost of care during the first 20 days of care in a SNF. For the 21st through the 100th days, the patient must share the cost of care by paying a daily coinsurance rate, or a Medicare supplement can pay it. For 2021, the coinsurance amount is $185.50 (this changes annually).
Covered services under Medicare include:
- A semi-private room
- Meals, including special diets
- Regular nursing services
- Rehabilitation services
- All Drugs
- Medical supplies
Medicare does not cover:
- Personal convenience items
- i.e. telephones
- beauty/barber shop etc.
Private duty nurses:
Extra charges for a private room.
Medicare Part B may help pay for covered services you receive from your doctor in a SNF, if you choose to participate in the Part B medical insurance program. If you have used up your Part A coverage for a spell of illness, Part B also covers a portion of services received in a SNF, such as physical and occupational therapy. Under the Part B program, you must pay an annual premium and a deductible for all Part B services including physician services, after which Medicare pays 80 percent of the reasonable charges for covered services.
Some services that are not included under Part B are:
- Routine physical examinations and tests
- Routine foot care
- Eye or hearing exams for prescribing or fitting eyeglasses or hearing aids
- Immunizations, except flu and pneumonia
How to Apply for Medicare - Contact your nearest Social Security office to find out if you are automatically covered for Part A because of credits for number of quarters worked in your lifetime. Also, if you are interested in signing up for Medicare medical insurance (Part B), the Social Security office can assist you with that process as well. Keep in mind, though, that you can only sign up for the insurance in the first three months of the calendar year.