Medicare Benefits and Long Term Care
What is Medicare?
Medicare is the federal health insurance system for persons:
- 65 years or older
- Under 65 with certain disabilities
- Of all ages with End Stage Renal Disease
You can enroll in “Original Medicare” or a “Medicare Advantage Plan.”
The Medicare website provides information to Veterans and caregivers, including:
- Medicare eligibility tool
- Help with enrollment
- List of covered services
- Tips on selecting a Medicare plan
- How to get help paying Medicare costs
- Directory of Medicare-certified providers
Medicare and Long-Term Care Benefits
Long Term Care Benefits
Original Medicare will pay for services in a skilled nursing home and some home health services. Medicare Advantage Plans are required to provide the same benefits, however they may charge different copays and/or change the eligibility standards.
Skilled Nursing Facility (SNF)
You can receive care in a skilled nursing facility for a limited number of days (Original Medicare helps pay costs for up to 100 days in a benefit period) if your doctor decides that you require skilled care after a hospital stay. The facility must be certified by Medicare. Skilled care means services are provided by skilled nursing or rehabilitation staff, such as a nurse or physical therapist.
Your Skilled Nursing Facility Costs under Original Medicare
- Days 1 - 20: $0 for each Benefit period
- Days 21 - 100: $170.50 Coinsurance per day of each benefit period
- Days 101 and beyond: all costs
If you selected a Medicare Advantage Plan, your costs will vary based on that specific plan.
Home Health Services
If your doctor decides that you are home-bound (your condition keeps you from leaving home without significant effort), then you may be eligible for home health services under hospital insurance (Part A) and medical coverage (Part B). Covered services may include (but are not limited to):
- Intermittent skilled nursing care
- Rehabilitation (physical/occupational/speech therapy)
- Assistance with daily activities
- Medical supplies/equipment to use at home
Services must be ordered by a physician and provided by a Medicare-certified home health agency for Original Medicare enrollees. Medicare Advantage Plan members must use a home health agency that accepts their plan’s payment.
What is NOT covered by Medicare?
Custodial care is help with personal care needs such as dressing or bathing. If the ONLY type of care you need is custodial, then Medicare will not pay for your care in a nursing home or in your own home. Medicare may cover medical and rehabilitation services provided in an Assisted Living Facility, such as home health care ordered by your provider, but typically will not cover the costs of the facility – such as rent and meals.
Medicare Benefits and Enrollment
Original Medicare
There are 3 components, or “parts,” of Original Medicare services:
- Hospital Insurance (Part A)
- Medical Insurance (Part B)
- Prescription Drug Coverage (Part D)
If you enroll in Part A, you can also enroll in Parts B and D. Here is a summary of the long term care services provided in each of these parts:
- Hospital Insurance (Part A) provides coverage for services for inpatient care in a hospital, skilled nursing facility, hospice care, and some home health care services. Most people over 65 have paid Medicare taxes while working and will automatically receive this coverage without having to pay a monthly premium.
- Medical Insurance (Part B) provides coverage including doctor’s services, outpatient hospital care, and some home health care. Part B enrollment is voluntary, and you will be charged a monthly premium for this coverage. Your premium can vary based on your income, and when you signed up for the coverage.
- Prescription Drug Coverage (Part D) is provided by insurance companies and private companies approved by Medicare. Part D enrollment is voluntary, and you will be charged a monthly premium for this coverage. Your premium can vary based on when you signed up for the coverage.
Medicare Advantage Plans
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:
- Health Maintenance Organizations
- Preferred Provider Organizations
- Private Fee-for-Service Plans
- Special Needs Plans
- Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan:
- Most Medicare services are covered through the plan, and
- Medicare services are not paid for by Original Medicare
Most Medicare Advantage Plans offer prescription drug coverage. You can apply online for the Medicare Advantage Plan.
How do I enroll in Original Medicare (Part A and Part B) benefits?
Automatic Enrollment
Many people are automatically enrolled in Medicare benefits (Part A and B) because they are already receiving Social Security benefits or Railroad Retirement Board (RRB) benefits. In this case, Part A and Part B enrollment starts the first day of the month you turn 65.
If you are under 65 and disabled, Part A and Part B enrollment starts after you receive disability benefits from Social Security or certain RRB disability benefits for 24 months.
If you are enrolled automatically you will receive a red, white, and blue Medicare card in the mail three months before your 65th birthday or your 25th month of disability benefits if under 65 years old. Instructions will be included with your card to decline Part B coverage if you do not want it.
Sign up for Benefits
Some people who are eligible are not automatically enrolled and need to sign up for Part A and Part B benefits. Most often these people are those who are 65 or older but not receiving Social Security or Railroad Retirement Board benefits.
To sign up for benefits:
- Visit your local Social Security Office, or
- Apply at www.SocialSecurity.gov, or
- Call Social Security at 1-800-772-1213
- If you worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772
Is there help for me to pay my Medicare out-of-pocket costs?
- If you are low-income, you may qualify for Medicaid to assist you with your Medicare costs.
- You can purchase a Medigap policy from a private company. Medigap supplemental Medicare insurance policies can help you pay for Medicare costs such as Part A and Part B deductibles, copays, and coinsurance.
