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Medicaid and Medicare Overview

“Medicare and Medicaid do not pay for an unlimited amount of long-term care.”

Medicare and Medicaid do not pay for an unlimited amount of long-term care. How these various government-sponsored insurance programs work can be confusing.

Medicare is an insurance program backed by the US government for those over 65 years of age, as well as people with specific disabilities or kidney disease. For medical treatment to be covered under Medicare, it must meet certain standards, including approval by a medical professional. Treatment must be provided by a Medicare-certified partner, like Senior Care Centers, to be covered.

Medicare Part A:

  • Part A pays all or part of the costs for 90-day inpatient hospital stays. Patient pays deductible upon admission to hospital and co-pay on days 61 through 90
  • For skilled nursing facility treatment to be covered, a patient must have had a hospital stay of minimum 3 nights and been transferred to a skilled nursing facility with 30 days of being discharged.
  • Part A covers qualifying skilled nursing treatment for up to 100 days per benefit period, with the first 20 being paid in full by Medicare and the last 80 requiring a co-pay. For benefits to regenerate, you must not be receiving skilled nursing treatment, in our out of a facility, for at least 60 consecutive days.
  • If a patient opts for hospice care in a qualifying Medicare program, Part A covers most of the cost.

Medicare Part B:

  • Requires $124 deductible per year, along with 20 percent of all Medicare approved charges beyond that. Part B pays the other 80 percent relating to:
  • Unless you intentionally opt out, enrollment in Part B is automatic when you enroll in Part A. Premiums are required for coverage under Part B.
  • Medical and surgical procedures the patient receives in a physician’s office, a hospital, a skilled nursing facility, or at home;
  • Diagnostic tests and procedures related to treatment;
  • The medical opinion of a second physician when appropriate;
  • Services received in an emergency room or outpatient clinic;
  • Mental health care in a hospital outpatient setting;
  • Medically necessary ambulance transportation;
  • Qualified Durable Medical Equipment (e.g., oxygen equipment and wheelchairs);
  • Outpatient physical, occupational and speech therapy;
  • Other designated services.

Medicare Part D:

Part D covers prescription medications for those enrolled in Part A or B, with standard and low income plans for those on fixed incomes. Enrollment is not automatic like with Part B – you must intentionally enroll in Part D if you want coverage. A co-pay, monthly premium, and yearly deductible are required.

Medicaid:

Medicaid is a state-administered program – meaning it can differ from state to state – that pays for skilled nursing coverage pending you meet certain eligibility requirements set by the federal government. These include, but are not limited to:

  • Patient must be at least 21 year old
  • Patient must be US citizen or resident alien.
  • Patient must have a medical need for nursing facility services, as noted by a qualified medical professional
  • Patient’s monthly income and countable assets must not exceed the eligibility limits set by the state

As long as one meets the eligibility requirements, they continue to receive coverage.

Medicaid: Medical Necessity Requirements.

You or your loved one, must require the care of a skilled nurse on a daily basis in order to meet medical necessity requirements. Some examples include:

  • Complex wound care
  • IV therapy
  • Diagnosis of Legal Blindness
  • Cognitive deficits such as Alzheimer's Disease or Dementia
  • Seizure Disorder
  • Other care that requires a skilled nurse daily

Custodial care, such as assistance bathing, toileting, eating, mobility alone does not meet medical necessity requirements.

Medicaid: The Two Financial Requirements Involve Income and Resources: Income as of 2014

Maximum gross income

  • Individual and individual with an ineligible spouse - $2,199
  • Couple (if both parties are in the facility) - $4,398

What counts as income?

  • Social Security Benefits
  • Certain Veterans Benefits
  • Private Pensions
  • Interest & Dividends
  • Royalty & Rental Payments
  • Federal Employee Annuities
  • Railroad Benefits
  • State & Local Retirement Benefits
  • Gifts & Contributions
  • Earnings & Wages
Resources as of 2014

Maximum countable resources

  • Individual - $2,000
  • Couple - $3,000

What is a resource?

  • Bank Accounts & CDs
  • Real Estate Property
  • Life Insurance Policy Cash Value
  • Burial Funds
  • IRA
  • Stocks & Bonds
  • Oil/Gas/Mineral Rights
  • Jewelry & Antiques
  • Cars & Other Vehicles
  • Boats & Recreational Vehicles

What can be excluded?

  • Homestead where the individual intends to return.
  • Life insurance if the face value is $1,500 or less
  • Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial)
  • Car, regardless of value
  • Burial spaces

Protected resources amount for a spouse in the community

  • $23,844 Minimum - $119,220 Maximum (Excludes value of homestead, household goods, personal goods, one car, and irrevocable preneed burial funds). Assets are only protected for 1 year. Within that year the assets can be transferred to only the spouse with no penalties.

Meet with a facility Business Office Manager to complete Medicaid Application and discuss your specific situation. The following items are will need to be provided when completing a Medicaid Application:

  • Bank records from the current and past three months
  • Life insurance policies (Include Cash Values and policies of spouse)
  • Proof of income (Awards letter showing gross and net amounts received)
  • Property information (land titles, vehicle titles, etc.)
  • Wage garnishments

Note: Medicaid eligibility requirements for a long-term skilled facility is not the same as community Medicaid requirements.

Medicaid: What to expect after qualifying?
  • You or your loved one’s income will be applied towards care received at the long term care facility with the exception of a Personal Needs Allowance that is determined by the Texas Medicaid Program.
  • Individual: Total gross income less $60 for personal needs.
  • Individual with a spouse in the community: Total gross couple income less $60 for personal needs, less $2,980.50 for community spouse, less certain amount for dependents living with community spouse.
  • Couple: Total gross income, less $120 for personal needs.

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