WHAT IS MEDICARE?
Medicare is a federal health insurance program for most people over 65
years of age and certain people with disabilities that are under 65.
Medicare provides basic healthcare coverage, but it does not cover all
of your medical expenses, nor the cost of most "long-term" care.
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HOW DO I GET MEDICARE COVERAGE?
In order to get coverage you must enroll in the Medicare program.
If you are receiving Social Security or disability benefits, the Social
Security Administration will contact you a few months before you become
eligible for Medicare and will provide you with the information you need
to enroll.
If you are no already getting checks from Social Security, then you
should contact the Social Security Administration about 3 months before
you 65th birthday. You can sign up even if you do not plan to retire at
65. Initially you have 7 months to sign up for medical insurance (Part
B). This 7-month period begins 3 months before your 65th birthday,
including the month you turn 65 and ends 3 months after your birthday.
If you do not enroll during this initial enrollment period, each year
you are given another chance to sign up during a general enrollment
period from January 1st through March 31st. Your coverage begins the
following July. Your monthly premium increases 10 percent for each
12-month period you were eligible but did not enroll.
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WHAT IS THE DIFFERENCE BETWEEN WHAT MEDICARE A AND B COVERS?
Medicare Part A is considered "hospital insurance" and helps pay for
inpatient care in a hospital or skilled nursing facility (SNF), home
healthcare and hospice care. Except for home healthcare, all are subject
to a benefit period. Currently Medicare A fully covers and pays for the
first 20 days of an inpatient stay in a SNF< however from day 21 up to a
maximum of 100 days. The recipient is responsible for a $99.00/day
deductible for 2001 as long as there has been a qualifying hospital
stay.
Medicare Part B is considered "medical insurance" and helps pay for
physician's services and many other medial services and supplies such
as; ambulance services, outpatient hospital services, X-rays, labs, and
outpatient or long-term care rehab therapy services (PT, OT, SLP) for
Medicaid or private pay patients that are not covered by the hospital
insurance part of Medicare. In most cases, Medicare Part B covers 80% of
the cost of the services and the recipient is responsible for the
remaining 20%.
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WHAT IS A "BENEFIT PERIOD"?
A benefit period is a set period of time for which Medicare will cover
services. For example, if you need inpatient care, Medicare Part A
(hospital insurance) helps pay for up to 100 days in any hospital or a
Medicare Certified SNF as long as you continue to qualify under the
terms specified by the Federal government. The payment however is
subject to certain deductibles and co-insurance.
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WHAT QUALIFIES SOMEONE FOR MEDICARE PART A?
1. 3 consecutive overnights in a hospital.
2. Admission into a Medicare SNF bed within
30 days from the hospitalization.
3. Patient has not exhausted their 100-day Medicare benefit.
4. Patient requires 7 days a week skilled nursing care and/or 5 days a
week of therapy (Physical, Occupational, and/or Speech Therapy).
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IS THERE ANY ADDITIONAL INSURANCE AVAILABLE TO
HELP COVER THE MEDICARE DEDUCTIBLES?
Co-insurance plans, such as Medigap and Medex
can be purchased from commercial insurance
providers and are available to help cover some of
the additional costs for both inpatient and
outpatient healthcare.
Medigap and Medex plans can cover any deductibles and/or co-payments for
days 21-100 of a qualifying SNF stay, and/or for the 20% portion of the
Medicare Part B. Additionally, Medicaid can also pay co-insurance and
deductibles for Medicare A and B if the patient is eligible.
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WHAT IF I HAVE ANOTHER HEALTH INSURANCE PLAN?
You need to contact your insurance agent to see how your health plan
integrates with Medicare insurance. Fortunately, many Health Maintenance
Organization (HMO) and commercial insurance plans now have "senior
plans" available, and may be able to continue to provide services to you
and your family. HMO/commercial insurance plans vary in regards to cost,
coverage, and benefits. Many HMO's/ commercial insurance companies
further define their coverage, or manage their patients care, through
the use of Preferred Provider Lists* and internal case management
review. We recommend that you familiarize yourself with your insurance
policy.
* A list of healthcare facilities or practitioners that are approved by
an insurance company to provide care to their members. Often these lists
are compiled to assure that quality care is provided.
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WHAT HAPPENS IF I HAVE ALREADY BEEN IN THE HOSPITAL OR IN A SKILLED
NURSING FACILITY THIS YEAR?
If your inpatient hospital and/or Medicare A SNF stay was more than 60
days ago, and you qualify (see "What qualifies someone for Medicare Part
A') with a new hospital stay then you are eligible for a new 100 day
benefit. However, if it has not been 60 days since your last
hospitalization and/or SNF stay, then you will still be working off your
initial 100-day benefit.
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WHAT IS MEDICAID?
Medicaid is state regulated health insurance coverage for individuals
who meet specified income limitations for short and long-term inpatient
stays. Once a person qualifies both financially and medically, Medicaid
will pay for all needed/authorized healthcare services. Medicaid expects
long term care patients to contribute to the cost of their care expenses
by remitting a portion of their Social Security check to the facility;
the amount varies by spousal/dependent income, needs, etc.
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ALONG WITH MEDICARE AND MEDICAID, WHAT OTHER HEALTH INSURANCE COVERAGE
IS ACCEPTED AT SPEC?
Sudbury Pines Extended Care has contracts with Blue Cross/Blue Shield
and Harvard Pilgrim Health Plan. Sudbury Pines Extended Care is willing
to negotiate will all HMO's and commercial insurance companies. Our
staff will work diligently with you to maximize your benefits and extend
your inpatient stay long enough to allow you to reach your highest
potential.
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