1 / 14

Medicare Basics

Medicare Basics. Health insurance Covers ACUTE care needs Skilled care only Medicare’s definition of skilled Rehab & recovery focus Must show progress Only for: “Short-term, skilled, recovery-based care”. LTC Funding Sources. Medicare 14% “Short-term,” skilled care only

moanna
Download Presentation

Medicare Basics

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Medicare Basics • Health insurance • Covers ACUTE care needs • Skilled care only • Medicare’s definition of skilled • Rehab & recovery focus • Must show progress • Only for: “Short-term, skilled, recovery-based care” For Professional Education Only

  2. LTC Funding Sources • Medicare 14% • “Short-term,” skilled care only • Individuals/Families 23% • Medicaid (welfare) 45% • VA 3% • Other 4% • Private Insurance 11% (LTCi?) Centers for Medicare & Medicaid Services, 2000 For Professional Education Only

  3. Skilled vs. Non-skilled • Medicare only covers “skilled” care • IVs, regular injections, tube feeding, physical therapy, speech therapy, continuous O2, close monitoring round-the-clock, etc. • AND must show progress toward recovery. • Daily (SNF) • In acute and sub-acute facilities • “Intermediate,” not daily (HHC) For Professional Education Only

  4. Skilled vs. Non-skilled • Medicare does NOT pay for non-skilled care (custodial care) ... unless it does ... • Non-skilled services are only covered when received as part of an approved “skilled” care need: • ADLs in the SNF • Bathing/dressing visit at home • If no Medicare-approved “skilled” care, then NO benefits for custodial services. For Professional Education Only

  5. Skilled Nursing Facility (SNF) • Following 3-night inpatient hospitalization • Enter SNF w/in 30 days for same reason • THEN: • Days 1-20 covered 100% • Days 21-100 covered after co-payment • 2004 = $109.50/day • But only IF receiving daily “skilled” care For Professional Education Only

  6. Home Health Care • Not subject to prior-hospitalization • Unlimited* • BUT • Must need “skilled” care; intermittent basis • Must be homebound • Under physician’s care • Separate custodial visits covered For Professional Education Only

  7. Medicare & Managed Care • 1983 • Part A Hospitalization • Prospective Payment System (PPS) based on Diagnosis Related Group (DRG) • Within 18 months SNF admissions +40% • Great for SNFs & HHC industry, but ... For Professional Education Only

  8. That was then ... • Prior to 1998 • Extensive abuse by providers extending skilled services beyond guidelines or classifying chronic custodial needs as skilled or rehabilitative • Avg. covered SNF stay, 50 days • “But Medicare paid for my Aunt Betty’s home care for nearly a year ...” For Professional Education Only

  9. That was then ... • Between 1992 and 1997, Medicare: • HHC providers increased - 6,000 to 10,000 • HHC budget - $7-billion to $18-billion • HHC visits - 125-million to 300-million • The caregiving industry forced Medicare back to the basics: Skilled care only ... For Professional Education Only

  10. ... this is now • Substantial reform starting in 1998 • SNFs on a form of prospective payment • Based on “Resource Utilization Groups” (RUG) ... Similar to the hospital DRG system • Avg. Medicare-funded stay down to 14 - 21 days • HHC agencies also on RUG flat fees For Professional Education Only

  11. Medicare and LTC • Medicare covers some “care” costs • But only for: “Short-term, skilled, recovery-based needs” • Medicare does not cover non-skilled, custodial care • Med-Sup plans only pick up Medicare-approved deductibles & co-pays • Medicare is NOT a payer for LONG-term care. (>90 days) For Professional Education Only

  12. Major Medical (<65) • Major medical for working-age adults also only covers “skilled” care • Look at exclusions: • “Custodial care” • Most limit number of days of SNF and HHC even if skilled care needed • This is why 50-year-olds should by LTCi! For Professional Education Only

  13. Medicare and LTCi Plans • Do not rely on Medicare to cover 90/100-day EP • A few carriers may still coordinate with Medicare during the EP – Medicare-paid days will not count without other paid, covered services • Clients need to plan for LONG-term, CUSTODIAL care needs For Professional Education Only

  14. Medicare Planning • Initial eligibility @ 65 ... Even though full SS retirement age increasing • Potential for mistakes if Medicare delayed • Continued group coverage past 65 tricky • Can only delay Part B enrollment if WORKING and covered by a LARGE group (20+ ees) medical plan • COBRA & “retiree” coverage is 2ndary For Professional Education Only

More Related