Medicare can be confusing, frustrating and a blessing all in the same thought. Here’s a quick layout of Part A and Part B coverage.
With Medicare open enrollment closing today, you may be scrambling to help your elder change plans or investigate other plan options. Here is a quick guide to the difference in Part A and Part B coverages.
I’ve borrowed some of this information straight from Medicare.gov. After all, they’re the experts on the program.
Medicare Part A covers:
- Hospital stays as an inpatient
- Skilled nursing facilities (after a 3 day qualifying inpatient hospital stay)
- Home health services (this is limited and not what you think of when you think of home health assistance)
Hospital stays –
- Coverage includes a semi-private room (unless a private room is medically necessary), meals, nursing care, medications and other services while in the hospital.
- It does not include “extras” if they are charged separately by the hospital, like TVs, phones, cozy socks or the “cute pan” everyone gets.
- Private-duty nursing is not covered in Part A.
- Payment is for inpatient care only via Part A. A person can be in a hospital but not be considered an inpatient. ASK EVERY DAY your elder is there – Are they being treated as an inpatient today or as an outpatient?
- A MOON (Medicare Outpatient Observation Notice) is given to the patient when they are being treated as an outpatient under observation. Make sure you check for this document if your elder is under observation only.
Skilled Nursing Facility (SNF) stays –
- If your elder was an inpatient at a hospital or acute care facility for 3 days (at minimum, not including day of discharge), they will qualify based on doctor’s orders for a stay at a skilled nursing facility. Often these are called rehabilitation (rehab) facilities.
- Stays at SNFs are when a patient needs skilled nursing care or skilled therapy care necessary “to help improve or maintain” a current condition, per Medicare.
- Doctor must order or confirm that daily skilled care is necessary.
- If your elder receives a MOON, they most likely are not qualifying for SNF care, unless they have been admitted as an inpatient for 3 days after they receive the MOON.
- SNF care is usually covered for the first 20 days of care. After that, the care must be re-certified as medically necessary and there can be coinsurance to pay per day.
- Medicare does NOT pay for long-term care!
Hospice care –
- To enter hospice, a doctor must certify that the patient has a condition or illness that gives them a life expectancy of 6 months or less. Medical words – terminally ill.
- Hospice coverage includes medication and supplies needed for pain management and symptom relief.
- Services of a hospice medical team, including doctors and nurses.
- Social services of a social worker and, if desired, a chaplain. Grief counseling.
- Medical equipment necessary for care
- Aide and homemaker services (get this clearly explained by the hospice agency as it is often unclear and left for you to request)
- Hospice care is provided in the home or facility where the patient lives. Inpatient hospice care is not covered unless the medical team determines that acute care is needed that cannot be given at the residence where the patient is living (this is VERY limited).
- Curative treatments are discontinued when a patient enters hospice.
- Respite care of up to 5 days for the primary caregiver to get some rest is paid for under this service.
- Hospice coverage continues as long as the patient is certified by a doctor to be terminally ill.
- The patient and family have a choice in hospice coverage. My recommendation is to interview at least 3 hospice agencies.
Home Health Services –
- These services can be covered by Part A or Part B Medicare coverage.
- Home health services include therapy services (physical, occupational, speech, cognitive) and “medically necessary part-time or intermittent” skilled nursing care. Examples of skilled nursing care would be wound care, blood pressure or vital checks, injections, etc.
- A doctor must request these services after the doctor or medical professional working with the doctor sees the patient in person. The doctor must then order the care. The care is usually limited to a certain timeframe, depending on the type of care needed.
- Other supplies and services can be included under this heading for the homebound patient.
- If the blood the patient receives is donated, there’s no charge.
- If the hospital or facility purchases the blood, the patient pays for the first 3 units.
Medicare Part B covers:
- Doctor visits and care
- Outpatient care and services
- Home Health Services (see above)
- Durable medical equipment
- Mental health services
- Other medical services, including much preventative care.
I’m not going to go into all the services that are covered in Part B. The list is long and detailed. You can find a great list on Medicare.gov or in the Medicare & You pamphlet sent to all Medicare enrollees every Fall.
Basically, Part B covers the services and care received when the elder is not being treated as an inpatient in either a hospital, SNF or in hospice.
Remember, Medicare doesn’t cover:
- Most dental care, including dentures*
- Most vision care related to prescriptions for glasses or contacts* (except for after cataract surgery)
- Hearing aids and hearing exams*
- Cosmetic surgery
- “Concierge” care
- MOST IMPORTANT TO KNOW – Long-Term Care
* Some Medicare supplement and Advantage plans have coverage that can be purchased for these areas.
The specifics of Original Medicare, supplemental “gap” plans and Medicare Advantage plans are not discussed here. That’s because we’d have to share more than a few moments to get all that clarified. Check out that chapter in my book for the low-down on those topics.
Now, is it all as clear as mud? I hope it’s a little better than before you started reading my blog.