Medicare and Medicaid Facts For Seniors
Medicare and Medicaid are not the same despite what some people think. And even though they have been around for an extremely long time, many people still confuse these two healthcare programs.
Medicare and Medicaid are U.S. government-sponsored programs designed to help cover healthcare costs for US citizens. Funded by taxpayers, these two programs have similar-sounding names, which makes it even more confusing to remember how they work and the coverage they provide.
Medicare is a federal program. It provides coverage for people over age 65, and people under age 65 who qualify due to a disability. Medicare generally does not cover assisted living or an extended stay at a nursing home/facility. What is included in Medicare are:
Part A (hospital insurance)
Part B (medical insurance)
The other two “parts” of Medicare, also don’t cover assisted living costs:
Part C (Medicare Advantage)
Part D (prescription drug coverage)
Home Health Benefit
If you qualify for the home health benefit, Medicare covers the following:
Skilled Nursing Services: Services performed by or under the supervision of a licensed or certified nurse to treat your injury or illness with a doctor’s order.
Services may include teachings and care for injections, tube feedings, catheter changes, observation and assessment of your condition, management and evaluation of your care plan, and wound care.
Skilled Therapy Services: Services performed by certified or licensed therapists and must be related to treating illness or injury.
- Physical therapy – Rebuild Strength or Gain Movement
- Speech-language pathology services – Speech and Language, Swallowing Skills, Memory
- Occupational therapy – Daily Activities/ Personal Care Skills.
Home Health Aide: Medicare pays in full for an aide to assist a couple hours per week if you also require skilled care, skilled nursing or therapy services with a qualifying need and a physician’s orders. .
What is A home health aide? A home health aide will provide seniors with personal care services. Personal care services – bathing, toileting, and dressing.
*Medicare DOES NOT pay for an aide if you only require personal care and do not need skilled care. You must require both for medicare to pay.
Medical Social Services: Medicare pays in full for services ordered by your doctor to help you with social and emotional concerns that might be related to your illness. This includes counseling or other community resources.
Medical supplies: Medicare pays in full for certain medical supplies.
Examples: Dressings and catheters
Durable medical equipment (DME): Medicare pays 80% of its approved amount for certain pieces of medical equipment, such as a wheelchair or walker every five years. You pay 20% coinsurance (plus up to 15% more if your home health agency does not take assignment).
Medicare should pay for these services regardless of whether your condition is temporary or chronic.
Nursing Home Benefit
After a three night admission, observation is not an approved night, to a hospital and a qualifying need for rehab/therapy, Medicare may pay for 100% of rehab at a rehab facility. This stay may include physical, occupational and speech therapy for up to twenty days as long as the patient is progressing and participating. If there is continued need for additional therapy after day twenty, Medicare pays 80% and if there is a coinsurance/supplement, it may pick up the additional 20% for up to a total of 100 days as long as there is progress and participation with a doctor’s order and insurance approval. At any time if the progress stalls or the participation is not there, the patient will be discharged from the facility or asked to pay privately for additional rehab or stay.
Medicaid: Medicaid is a health insurance program run by states. It provides coverage for people with low incomes.
Medicaid Eligibility Requirements
To be eligible for Medicaid long term care, you must qualify both financially and have a medical need for care. Eligibility requirements are specific to each state, the Medicaid program or waiver, and one’s age group.
The medical requirements for Medicaid long term care differ significantly by state. Generally speaking, any person who requires ongoing skilled nursing care, is mentally impaired with Alzheimer’s/dementia or is unable to care for him or herself can qualify.
What Happens if Skilled Nursing Care is Not Required?
Then many Medicaid programs will make eligibility contingent on the number of activities of daily living (ADLs) that an individual requires assistance with each day. Each state defines that level of care differently.
Examples of Activities of Daily Living:
Qualifications differ from state to state. In most states a person’s income and assets are taken into account when determining qualification. With the appropriate planning, many seniors can qualify for Medicaid. Medicaid does have a five year lookback in Kentucky and Indiana. This lookback period checks for expenses and transfers of wealth and assets within the last five years to verify eligibility.
Contact Elder Care
ElderCare 4 Families is happy to help provide elder care to seniors you know wherever they call home. Complimentary assessments are offered with no obligation by Elder Care, Personalized care is offered from 1 hour up to 24//7. With over 39 years of elderly care experience in the Louisville and Southern Indiana area, trust Elder Care to care for the seniors in your life. Call us at 502-244-8446 to start receiving Eldercare services in Louisville or with any other questions related to medicare and medicaid or senior care.