Making Sense of Medicare

 In Resources

As a former hospital social worker, I constantly educated patients in the hospital about what their Medicare plans covered and what their benefits mean. Here, I put together a guideline about what I’ve learned about Medicare benefits to answer questions I’m frequently asked.

Medicare Part A covers an inpatient stay in a hospital, skilled nursing, or acute rehab facility.  When Medicare pays for these services in one of these settings, they typically consolidate the billing.  This means, Medicare has a flat rate that they give the billing facility.  Of the money received, the facility has to pay for everything medically necessary for the patient (room and board, medications, therapies, meals, etc.)  Medicare A is a short-term payer and pays for a limited number of days.

A person becomes qualified for skilled nursing care when he or she is in the hospital as an inpatient for 3 consecutive midnights and has a need for higher level of care.  Medicare covers up to 100 days of services; the first 20 days in full, and from day 21-100 at 80%.  Most secondary insurances cover the remaining 20%.  A person does have to willingly participate and show progress to continue with their skilled days. When a person stops improving with therapies, Medicare stops paying.

Medicare Part B covers outpatient services.  In a skilled nursing facility, residents can get therapy under this benefit, but are subject to “therapy caps,” which is a dollar amount instead of a number of days. Medicare B will pay for certain services in a SNF but will not continue to pay room and board.

Medicare Part C plans are considered Medicare Complete replacement policies.  Instead of traditional Medicare, the insurance companies take a person’s Medicare benefits and provide a full coverage policy in its place.  These policies are typically cheaper than the Medicare policies with the Part D and Part F policies.  However, the insurance company must approve or authorize every service rendered.  The insurance company will look at things like compliancy, and progress toward goals. Authorization is needed for services to be provided and case managers must be called prior to any service being rendered.

Medicare Part D covers drug policy plans.  They cover copays for medications.  Medicare allows a certain monetary amount for medications in a year.

Medicare Part F plans are secondary plans.  They cover where Medicare leaves off.  Medicare Part B only covers 80% of services.  Part F plans pay the remaining 20%.  Some part F plans cover deductible costs and others require Medicare beneficiaries to cover those costs.  Medicare Part B has a $183 deductible.  Medicare Part A has a $1340 deductible.

This article was submitted by Bethany Borrenpohl, MSW, LCSW, owner and practitioner of Live Well Counseling Services, LLC. Live Well has proudly been providing counseling services to Medicare B recipients for two years and has grown to service over 50 communities, both skilled nursing and assisted living facilities. Clients can also receive counseling services under Medicare B if they are home-bound in their private home. For most of Live Well’s clients, their services are free from a combination of Medicare B and Medicare F plans, as mentioned in the article.