What many people do not know about Medicare coverage

I have worked in long term care for 15 years. I spend a lot of my time explaining Medicare benefits to patients and families about what is covered and what is not covered by Traditional Medicare (managed Medicare or Medicare part C is another beast all of its own). Many people are really quite shocked about the answers I give them. Please be aware you can always find out more information from MyMedicare.gov, or call 1-800-MEDICARE.

I will discuss some common misunderstandings I hear regarding Medicare coverage. My hope is that you will be more informed and educated about the coverage in the case that you or your loved one ever need in-patient skilled nursing rehabilitation.

I will start with the benefit days. Medicare allows up to 100 days in a skilled nursing and rehabilitation facility. What I want you to know is there is not a guarantee that all of those days will be used. The facility follows Medicare guidelines and the patient must meet specific criteria, especially by showing progress towards therapy goals. Oftentimes I have the burden of telling someone when they are no longer going to be covered by Medicare.

And by the way, Medicare only requires a 48 hour notice of non-coverage! Many are shocked and I hear, “but I thought I had 100 days”, or “the hospital or the doctor said I had 100 days”. Be aware there is never a guarantee so you should always be thinking proactively about what your plan would be when Medicare stops covering the stay in the facility.

You should also be aware that Medicare covers only 20 of those 100 days at 100 percent. If you do not have a secondary insurance or one that covers in a skilled nursing facility you are looking at $144.50 per day out of pocket expense. Medicare sets this co-payment, not the facility. Some secondary insurances do pick up a portion, others pick up all of the co-pay and others don't pick up any portion at all. Your individual policy should be verified during the admission process and the facility should make you aware of your secondary benefits.

Medicare does not cover intermediate or custodial care. This means that if you no longer meet Medicare skilled criteria, Medicare stops paying the bill. Many times I hear, “how can you just kick us out?”

I explain that the facility is not kicking any one out and that the person could stay, but they would be charged at an average rate of $210 to $240 per day plus ancillary and possible medication charges depending on their plan. Medicaid is an option at that point, but it is based on total assets/income. Going home is also an option and there are services available that assist people with staying in their own homes.

Hopefully you learned some things about Medicare that will assist you should you ever find yourself facing these situations.


Kristi Vaughn

I am a Licensed Social Worker.

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Volume 4, Issue 4, Posted 2:35 PM, 02.21.2012