Medicare

Submitted by Michael A. Manna, Attorney at Law. He can be reached at 201-447-2800.
Medicare is a federally funded health insurance program for the elderly and disabled. There is Part A Medicare and Part B Medicare.

A. Medicare Part A

A person is eligible for Medicare Part A automatically when they turn 65 years old or if they are disabled more than 2 years. Medicare Part A covers expenses in a hospital or a skilled nursing facility.

Medicare Part A can pay for up to 100 days per benefit period, which is per spell of illness. The first 20 days of eligibility are covered at 100%. Days 21-100 are partially covered by Medicare and the patient is responsible for the balance called the co-insurance amount. For example, in Saddle Brook, this co-insurance amount would be $124 per day for the year 2007.

A requirement for Part A coverage is that you must meet the Medicare criteria for coverage during the spell of illness. You are not guaranteed coverage. Before receiving Part A coverage in a skilled nursing facility, the patient must have first been in the hospital for 3 nights prior to admission to the facility or the patient must be admitted to a skilled nursing facility certified bed within 30 days of discharge from the hospital, unless there is a medical exception which is completed prior to discharges from the hospital.

The patient must have a skilled need to be eligible. Skilled need can be described as follows: A need for intensive physical, occupational or speech therapy as determined by a physician; the patient has a wound that requires daily intensive treatment; the patient is admitted for post surgical recovery; the patient is admitted for intravenous therapy; the patient must require skilled nursing or skilled rehabilitation services; the patient must require the skilled services on a daily basis (ex) skilled nursing for 7 days per week or skilled rehabilitation for 5 days a week minimum; the service must be provided on an in-patient basis in a skilled nursing facility; a physician must order the service or item; the service or item must be reasonable and necessary for treatment of the patients illness or injury; the service or item must be reasonable in terms of amount frequency and duration.

Medicare does not consider a patient needing constant supervision and assistance in feeding, dressing and taking medications to have a skilled need.

You can qualify for these Medicare days more than once in a calendar year if you: have a new illness/diagnosis; you have not received the same Medicare coverage in the past 60 days; you were not an in-patient in a hospital or other facility within the past 60 days.

Sub-acute programs are held in a licensed long-term care facility and are for patients who are medically stable and no longer require acute hospital rehabilitation care but are still unable to return home. Acute care would be in a facility such as a hospital, Helen Hayes or Kessler where you receive intense therapy. The acute care does not take away from your hundred days. The sub-acute program focuses on increasing the patient's independence as they reach goals set by themselves and set by rehabilitation and health care professionals. Sub-acute services offer quality care as the patient progresses through their post hospital recovery. After a patients sub-acute care is completed the facilities discharge planners assist in the patients return home so they can have a productive lifestyle since their functioning has been improved. The patient is medically appropriate for the sub-acute program if they will benefit from less intensive therapy (ex) physical therapy/occupational therapy/speech therapy, from 1-3 hours per day, 5 days a week or if they meet the medical requirements for sub-acute care still needing skilled medical treatment (ex) wound care, IV therapy, and tube feeding. A patient is financially appropriate for the sub-acute program if they are a Medicare patient and had a three day hospital stay prior to admission to the skilled nursing facility. Medicare will cover up to 100 days as long as skilled services are required. Medicare can stop at any time. If the patient no longer meets the medical requirements and the patients admission goals have been met then the clinical team at the facility will notify the patient in advance that their Medicare benefits will be terminated. The patient will have the option to appeal this decision but usually will not be successful.

B. Medicare Part B

People elect whether to have Medicare Part B or not and they pay a monthly premium. A person is automatically eligible for Part B if they are 65 years old or disabled. Part B covers ancillary services such as physician services, outpatient hospital services, durable medical equipment and ambulance services. Part B coverage pays 80% of the cost and the patient is responsible for a deductible and 20% co-insurance.
Editor's Note: Michael A. Manna is a Magna Cum Laude graduate of Boston College and a Cum Laude Graduate of Boston College Law School. After working in the tax department of the CPA firm of Peat Marwick Mitchell & Co., Mr. Manna entered the private practice of law in Ridgewood, New Jersey in 1975. Mr. Manna is admitted to practice in New Jersey, New York and Massachusetts and is a member of the bar of the Supreme Court of the United States. He is also a member of the National Academy of Elder Law Attorneys. He can be reached at 201-447-2800. Over the past thirty years, Mr. Manna has had extensive experience as a lecturer on legal topics for various boards of education and educational institutions. He can be reached at 201-447-2800.