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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

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Medicare Basics

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  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

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