As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
Q: My mother is in a skilled nursing facility. I was told that Medicare would cover her stay and her therapy. They just had a meeting and told me the Medicare coverage is ending. It has only been 15 days. I thought she had 100 days of coverage, what is going on?
A: Medicare Part A covers hospital admissions, nursing home stays for rehabilitation, home care and hospice. All of these benefits have co-pays or deductibles you may be required to pay. A hospital stay has a deductible of $1,184 for each hospital stay.
Your question was about skilled nursing facility (SNF) coverage. With this Part A benefit, each recipient could be covered for an SNF stay after a three-day hospital admission. Once in the SNF, each recipient has up to 100 days of coverage. When people read that sentence they see "100 days of coverage." What I want you to focus on is "up to." This phrase means the maximum amount of coverage you would have is 100 days. Most individuals who come for a rehab SNF stay do not get 100 days. They may stay five days, or 10 days or 24 days with coverage. At some point their condition improves enough that they no longer "qualify" for Medicare coverage of that stay.
This Medicare Part A SNF stay also has co-pays. With original Medicare, days one to 20 are paid in full by Medicare. If you are there 20 days or less you may not have any co-pay for your SNF stay.
At day 21, the co-pay goes to $148 per day. That is the amount you would pay for each additional day you stayed in the SNF. If you have secondary insurance, that may pick up that co-pay. If you are in an SNF for 24 days, the first 20 are covered in full, and the next four would cost $148 per day.
If Medicare coverage ends, you would pay full price (about $300 per day) for each of the additional days that you stayed in the facility.
Medicare Part A also covers therapies after some hospital stays. These therapies have similar limitations to their coverage. There are not a set number of days the way an SNF stay is defined, but your medical condition and diagnosis may qualify you for a certain number of therapy visits. If you progress and improve, that therapy may end sooner than you think. You may be eligible to get the therapy at home through a certified home care agency, or you may be required to go to a therapy office to get those services. Many hospitals provide out-patient therapies. These hospital out-patient therapy departments tend to be able to provide therapy longer before you max-out your benefit, depending on the diagnosis.
Always ask questions. Talk to your providers: the therapists, doctors and facilities you are dealing with. Do they feel there is a way you could qualify for more help?
You can always file an appeal to Medicare regarding this coverage ending. If you win the appeal, the coverage will continue for a longer period of time. If you lose the appeal, you are responsible for the bill.
When reading about the coverage of your insurance, it is hard to consider all the possibilities and how that insurance would cover it. We often don't learn of the limitations of our insurance, until it has happened. Talk to other people and see what their experience has been. Learn from their history and experience. Review your policies carefully to see what they cover and what you are responsible to pay for.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.