Skilled Nursing Facilities And Home Health Care
Under some circumstances, Medicare will cover some of the cost of inpatient treatment in a skilled nursing facility or visits from a home health care agency. Your stay in a skilled nursing home facility or home health care is covered by Medicare Part A only if you have spent three consecutive days, not counting the day of discharge, in the hospital. Your skilled nursing stay or home health care must begin within 30 days of being discharged. For more information, see our articles on Medicare coverage of skilled nursing facilities and Medicare coverage of home health care.
How To Read Your Bill
Once you receive a medical bill from your healthcare provider, you will notice that it consists of multiple components that might not be clear to you. For most patients, the codes, descriptions, and prices listed in their bills can seem confusing.
The following example explains each element of your bill with an in-depth description. It is important not to get your medical bill confused with the Explanation of Benefits , an insurance report we cover following the bill.
Hospital Stay And Skilled Nursing Facility Care
Under the Original Medicare program, you must be admitted and spend at least 3 days in the hospital as an inpatient before Medicare will cover your stay in an approved skilled nursing facility for further care. The time spent in both the hospital and the SNF count toward a benefit period. And you must have stayed out of both for 60 days to qualify for a new benefit period.
Your share of the costs in a skilled nursing facility is different from your share of the costs for hospital care. In a skilled nursing facility, in any one benefit period you pay:
- Nothing for your bed, board and care for days 1 through 20
- A daily coinsurance of $185.50 in 2021 for days 21 through 100
- All charges beyond 100 days
You cant use hospital lifetime reserve days to extend Medicare coverage in a skilled nursing facility beyond 100 days in any one benefit period.
Note that you may be able to sign up for a Medicare Supplement insurance plan to help pay for Original Medicares out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.
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Q Where Do I Go To Apply For Medicaid
A. There are several ways to apply for Medicaid and other medical assistance programs:
- On the internet, you can use ASSIST to check your eligibility for several different assistance programs by completing a self-screening questionnaire. ASSIST then allows you to apply online.
- You may also print an Application for Health Insurance/Medicaid. The application form is also available in Spanish/en Español.
- By phone, you can contact Medicaid Customer Relations at 1-800-372-2022 or 255-9500 to be directed to the Division of Social Services office closest to where you live. DSS staff members will help you find out more about eligibility for Medicaid and other assistance programs. Then the appropriate information and application forms will be mailed to you. Complete, sign and date the application form in ink and mail it to the address provided.
- For Long Term Care applications, please call the Long Term Care Medicaid Unit listed for the county where you live.
Medicare Part A Coinsurance
Once the deductible is paid fully, Medicare will cover the remainder of hospital care costs for up to 60 days after being admitted.
If you need to stay longer than 60 days within the same benefit period, youll be required to pay a daily coinsurance. The coinsurance applies to an additional 30-day period or days 61 through 90 if counted consecutively.
As of 2020, the daily coinsurance costs are $352.
After 90 days, youve exhausted the Medicare benefits within the current benefit period. At that point, its up to you to pay for any other costs, unless you elect to use your lifetime reserve days.
A more comprehensive breakdown of costs can be found below.
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What Happens When Medicare Runs Out Of Money
It will have money to pay for health care. Instead, it is projected to become insolvent. Insolvency means that Medicare may not have the funds to pay 100% of its expenses. Insolvency can sometimes lead to bankruptcy, but in the case of Medicare, Congress is likely to intervene and acquire the necessary funding.
Should I Use Medicaid To Pay For My Hospital Bills After An Accident
Nearly 70 million Americans receive Medicaid as of August 2020. If youre one of them, its important to know the role it will play if youve been involved in an injury-causing accident.
If you are a Medicaid recipient then Medicaid will pay your medical bills at a greatly discounted rate. Because of that, its a good idea to use it to pay for all of your healthcare treatments, including after a car accident.
However, keep in mind that at Wagner Reese, its our goal to get you paid via the at-fault party and their insurance provider, which can ultimately result in more money for you and your loved ones than if you rely on Medicaid coverage alone.
Medicaid only pays for medical expenses relating to an injury and/or illness, it does not pay for other losses such as lost income, pain and suffering and physical impairments caused by a car accident. These losses are the responsibility of the at-fault party.
What Does Medicare Part B Cover
Medicare Part B covers doctor visits and most routine and emergency medical services. It also covers some preventive care, like flu shots.
What is covered by Medicare Part B
- Doctor visits, including when you are in the hospital
- An annual wellness visit and preventive services, like flu shots and mammograms
- Clinical laboratory services, like blood and urine tests
- X-rays, MRIs, CT scans, EKGs and some other diagnostic tests
- Some health programs, like smoking cessation, obesity counseling and cardiac rehab
- Physical therapy, occupational therapy and speech-language pathology services
- Diabetes screenings, diabetes education and certain diabetes supplies
- Mental health care
- You enroll for the first time in 2021.
- You arent receiving Social Security benefits.
- Your premiums are billed directly to you.
- You have Medicare and Medicaid, and Medicaid pays your premiums.
Your Part B premium may be less than the standard amount if you enrolled in Part B in 2020 or earlier and your premium payments are deducted from your Social Security check.
Your premium may be more than the standard amount based on your income. You will pay an incomerelated monthly adjustment amount if your reported income from 2019 was above $88,000 for individuals or $176,000 for couples. Visit Medicare.gov to learn more about IRMAA.
And while Medicare will share your Part B health care costs with you, there is something called Medicare assignment thats important to understand.
Negotiation With Your Cob Contractor Is Difficult
Negotiating a settlement with Medicare is difficult and time consuming. Medicare usually likes to be reimbursed for all of your medical bills it paid if you receive a personal injury settlement. This is also true if your case is decided in court or through a type of alternative dispute resolution.
Typically, your COB contractor will send you a statement detailing all of your medical bills after he or she receives your lawyers notification of the settlement. If the information in the statement is correct, your lawyer will try to negotiate with Medicare and then he or she will send a check to cover the expenses from your settlement amount before disbursing the rest of the settlement to you. While you do not have to accept what the COB says, the appeals process is also difficult and time consuming and you must follow the Medicare internal appeals process.
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How Much Does A Medicare Claim For Hospital Services Cost
You may be responsible for some or all of the total cost of your hospital bill. The amount you pay depends on your personal health insurance coverage, as well as your health status.
Depending on your health, you may have either a deductible or a copayment. You must meet your deductible before your insurance coverage kicks in.
A copayment is a fixed amount you pay for covered services. You may have to pay more than this amount for certain services.
If you have Medicare Part B and a Medicare Part D plan, you may be required to pay a premium to cover your Part D coverage.
Medicare Part B also provides coverage for some medical equipment.
When you need long-term care, you might have to pay a deductible, copayment, or coinsurance for these services.
Medicare Part D may also pay for some of your long-term care costs.
C: Medicare Advantage Plans
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were formally given the option to receive their Original Medicare benefits through capitated health insurance Part C health plans, instead of through the Original fee for service Medicare payment system. Many had previously had that option via a series of demonstration projects that dated back to the early 1970s. These Part C plans were initially known in 1997 as Medicare+Choice. As of the Medicare Modernization Act of 2003, most Medicare+Choice plans were re-branded as Medicare Advantage plans . Other plan types, such as 1876 Cost plans, are also available in limited areas of the country. Cost plans are not Medicare Advantage plans and are not capitated. Instead, beneficiaries keep their Original Medicare benefits while their sponsor administers their Part A and Part B benefits. The sponsor of a Part C plan could be an integrated health delivery system or spin-out, a union, a religious organization, an insurance company or other type of organization.
The intention of both the 1997 and 2003 law was that the differences between fee for service and capitated fee beneficiaries would reach parity over time and that has mostly been achieved, given that it can never literally be achieved without a major reform of Medicare because the Part C capitated fee in one year is based on the fee for service spending the previous year.
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Medicaid Covers 1 In 5 Americans And Serves Diverse Populations
Medicaid provides health and long-term care for millions of Americas poorest and most vulnerable people, acting as a high risk pool for the private insurance market. In FY 2017, Medicaid covered over 75 million low-income Americans. As of February 2019, 37 states have adopted the Medicaid expansion. Data as of FY 2017 show that 12.6 million were newly eligible in the expansion group. Children account for more than four in ten of all Medicaid enrollees, and the elderly and people with disabilities account for about one in four enrollees.
Medicaid plays an especially critical role for certain populations covering: nearly half of all births in the typical state 83% of poor children 48% of children with special health care needs and 45% of nonelderly adults with disabilities and more than six in ten nursing home residents. States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden. Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care .
Figure 4: Medicaid plays a key role for selected populations.
Medicare Medicaid And Billing
Like billing to a private third-party payer, billers must send claims to Medicare and Medicaid. These claims are very similar to the claims youd send to a private third-party payer, with a few notable exceptions.
Since these two government programs are high-volume payers, billers send claims directly to Medicare and Medicaid. That means billers do not need to go through a clearinghouse for these claims, and it also means that the onus for clean claims is on the biller.
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Enrolling In Medicare Part B If You Are 65 Or Older Still Working And Have Insurance From That Job
You are not required to take Part B during your Initial Enrollment Period if you are still working or your spouse is still working and one of you has coverage as a result of that current work. You should only delay Part B if this current employer insurance is the primary payer on your health care expenses . You should talk to your employer when you become eligible for Medicare to see how employer insurance will work with Medicare. Generally, if you are eligible for Medicare because you are over 65, the employer must have more than 20 employees to be the primary payer. If you are eligible for Medicare because you get SSDI, the employer must have more than 100 employees to be the primary payer.
If there are fewer than 20 employees at the company where you currently work or your spouse currently works, Medicare is your primary coverage. In this case, you should not delay enrollment into Part B. If you decline Part B, you will have noprimary insurance, which is usually like having no insurance at all.
In either case, if you have insurance from a current employer, you qualify for aSpecial Enrollment Period . During this period, you can enroll in Part B without penalty at any time while you or your spouse is still working and for up to eight months after you lose employer coverage, switch to retiree coverage, or stop working.
Why File A Personal Injury Claim If You Receive Medicaid
If Medicaid will pay for your medical bills, why file a personal injury claim? Its a good question with several good answers.
- Your expenses could continue to pile upMedicaid doesnt pay you for future or anticipated costs. It only pays for the medical bills that you actually receive. In addition, not all healthcare-related costs are covered by Medicaid.
- Your Medicaid doesnt cover lost wagesAlthough Medicaid is typically offered to people in lower-income brackets, many still work and earn paychecks. But if your injury makes it impossible for you to work, your lost paychecks wont be covered by Medicaidonly your medical bills will be.
- Your pain and suffering deserve compensation, tooYou were just involved in a traumatic accident that may have forever changed your life. You may be in significant pain and suffer from disabilities for the rest of your life, both of which can make it impossible to enjoy favorite activities or spending time with family. A personal injury claim can compensate you for these losses.
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Does Medicare Cover Hospital Visits
Original Medicare is a federal health insurance program managed by the Centers for Medicare & Medicaid Services . It provides health-care benefits for American citizens and permanent legal residents aged 65 or older.
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Medicare also covers some people younger than 65 who might qualify for Medicare due to certain disabilities or health conditions.
Original Medicare is made up of two parts, Part A and Part B.
- Medicare Part A may cover certain costs if you are admitted to a hospital, skilled nursing facility, or hospice program. It may also cover limited home health services .
- Medicare Part B may cover outpatient care, physician services, durable medical equipment and supplies, and certain preventive medical services and diagnostic tests.
Medicare Part A generally helps pay for hospital inpatient care. For each benefit period, Medicare typically pays:
- All covered costs except the Part A deductible during the first 60 days
- Coinsurance amounts for hospital stays from 61 to 90 days
After 91 days, a coinsurance amount usually applies for each lifetime reserve day. You may get up to 60 lifetime reserve days during your lifetime.
The Majority Of The Public Holds Favorable Views Of Medicaid
Public opinion polling suggests that Medicaid has broad support. Seven in ten Americans say they have ever had a connection with Medicaid including three in ten who were ever covered themselves. Even across political parties, majorities have a favorable opinion of Medicaid and say that the program is working well . In addition, polling shows that few Americans want decreases in federal Medicaid funding. In addition to broad-based support, Medicaid has very strong support among those who are disproportionately served by Medicaid including children with special health care needs, seniors, and people with disabilities.
Figure 10: Large Shares Across Parties Say They Have a Favorable Opinion of Medicaid
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Medicaid Coverage Of Residential Senior Care
Due to the high cost of skilled nursing, which averages around $7,756 per month, Medicaid is an important source of funding for almost two-thirds of the nations nursing home residents. Medicaid picks up the slack once Medicare beneficiaries have exhausted their 100 days of skilled nursing facility coverage, and it covers individuals who need skilled nursing but dont qualify for Medicare.
Today, 43% of Medicaid long-term care spending goes toward care provided in skilled nursing and intermediate care facilities. The remaining 57% of funding goes toward waiver programs that allow members to receive long-term services and supports in assisted living facilities, senior living communities or their own homes. There are a few ways that Medicaid can help with the cost of long-term care:
- Nursing Homes: In addition to providing regular medical care, Institutional Medicaid pays for skilled nursing, personal care, room and board and specialized rehabilitative services provided in nursing homes.
- Assisted Living: Since assisted living facilities are less costly and less restrictive, many states will pay for these services through waiver programs. However, residents are still responsible for room and board.
- Community Housing: Nearly all Medicaid waivers will pay for the cost of personal care, home modifications and supportive services provided at home or in a residential setting, such as subsidized senior apartments.