Medicare and Medicaid

Did you know Skilled Nursing Facility (SNF) care after 100 days is NOT covered? Medicare will pay for 100% of the cost for the first 20 days and 80% of the cost for the next 80 days. Medicare Advantage plans AND certain Medicare supplemental insurance can help defer care costs even more. Between Medicare and these plans, 100% of the cost of skilled nursing could be covered for 100 days.

Most people have a need for additional help at the 20th day when the co-payments start to accrue, but especially after the 100th day when they will be responsible for the private pay amount. It is important to ensure you have been appropriately screened for public benefits prior to the 20th day. Medicaid can help mitigate these costs. You should complete the screening even if you believe you have the funds available to pay for the stay. Long-term care costs are high and can reduce your bank account easily. It’s important to ensure you meet the all the qualifications for public benefits in case the time comes when you need additional help.

Also, keep in mind, public benefit programs include a Care Certification requirement, meaning the individual demonstrated a continuation of care from the hospital to the SNF with no gaps in admission in order to qualify for most programs. A discharge to home before entering the SNF could disrupt this path and disqualify the individual from these beneficial programs. In most cases, individuals and families are not properly educated on their choices and end up discharging back to their home due to lack of finances, only to be readmitted again later with no option of applying for certain programs because their care certification was interrupted.

The good news is that while Medicare’s role in long-term care is complicated, with Legacy Senior Solutions
you can head off much of the headache that
comes with the financial burden of long-term care.

Medicare Program Information:

Medicare is a federal health insurance program for people 65 and older, people under 65 with certain disabilities and people of all ages with end-stage renal disease. Medicare is partly funded by payroll taxes from most employers, employees and all people who are self-employed. The Medicare program offers basic coverage to help pay for things like doctor visits, hospital stays and surgeries.

Medicare is broken out into four parts. Parts A, B, C and D.

Original Medicare: Medicare Part A and Part B are known as Original Medicare. This is the most basic coverage you can get and pays for hospital and medical services.

Medicare Part C and Part D: These are benefits available through private health plans and approved by Medicare. They’re both ways to enhance your health care coverage if you want more than what Original Medicare offers.

Part C, a Medicare Advantage Plan (like an HMO or PPO), is a Medicare health plan choice you may have as part of Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Part D, Medicare prescription drug coverage, is an optional benefit offered to everyone who has Medicare. To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.

Medicare Supplement (Medigap): A Medicare Supplement is another option for Medicare beneficiaries. A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that original Medicare doesn’t cover, like:

  • Copayments
  • Coinsurance
  • Deductibles

Medigap policies generally don’t cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. policies are sold by private companies. Some Medigap policies also cover services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. However, Medigap plans do not include Credible Prescription Drug Coverage, so you will also need a credible PDP with this option. If you have Original Medicare and you buy a Medigap policy, here’s what happens:

  • Medicare will pay its share of the Medicare-approved amount for covered health care costs.
  • Then, your Medigap policy pays its share.
  1. You must have Medicare Part A and Part B.
  2. A Medigap policy is different from a Medicare Advantage Plan.  Those plans are contracted by Medicare to administer your Medicare benefits for them, while a Medigap policy supplements your Original Medicare benefits.
  3. You pay the private insurance company a monthly premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare.
  4. A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
  5. You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one.
  6. Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
  7. Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
  8. It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you’re switching back to Original Medicare.



Questions about Medicare or how Medicare works with Medicaid?

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