What About Medicare?

There is a great deal of confusion about Medicare and Medicaid.

Medicare is the federally funded and state administered health insurance program designed for older individuals (i.e. those over age 65). There are some limited long-term care benefits that are available under Medicare. In general, if you are enrolled in the traditional Medicare plan, and you’ve had a hospital stay of at least three days, and then you are admitted into a skilled nursing facility (often for rehabilitation or skilled nursing care), Medicare may pay for a while. If you are a Medicare Managed Care Plan beneficiary, a 3-day hospital stay may not be required to qualify.)

If you qualify, traditional Medicare may pay the full cost of the nursing home stay for the first 20 days and continue to pay the cost of the nursing home stay for the next 80 days, but with a deductible that’s nearly $204.00 per day. Some Medicare supplement insurance policies may pay the cost of that deductible. For Medicare Managed Care Plan enrollees, there is no deductible for 21 days through 100, as long as the strict qualifying rules continue to be met. So, in the best case scenario, the traditional Medicare Managed Care Plan must pay up to 100 days for each “spell of illness”. In order to qualify for this 100 days of coverage, however, the nursing home resident must be receiving daily “skilled care” and generally must continue to “improve”. Note that once the Medicare and Managed Care beneficiary has not received a Medicare covered level of care for 60 consecutive days, the beneficiary may be eligible for the 100 days of skilled nursing coverage for the next spell of illness.

While it’s never possible to predict, at the outset, how long Medicare will cover the rehabilitation, from our experience, it usually falls far short of the 100 day maximum. Even if Medicare does cover the 100 day period, what then? What happens after the 100 days of coverage have been used?

At that point, in either case, you’re back to one of the other alternatives—long term care insurance, paying the bills with your own assets, or qualifying for Medicaid.

James E. De Martino is licensed to practice in the State of New Jersey.

Our practice is limited to estate planning, long-term care planning, and NJ Medicaid asset protection.