Long Term Care Provided by Medicare
A Insurance Article Contributed by Shobha Cutting
Long Term Care Provided by Medicare
Medicare was incorporated to provide universal, subsidized, long term medical care to every American. The program also took care of persons aged over 65 and certain younger disabled persons. There are about 40 million beneficiaries of Medicare today in the U.S. Medicare benefits include 20 days nursing at full cost and the actual cost of such care in excess of $109.50 per day, for another 80 days. Private Medicare supplement generally pays up to $109.50 per day for 80 days.
However, all Medicare payments usually stop before reaching 100 days. To be entitled for Medicare, the beneficiary must spend at least 3 days in a hospital and a doctor must recommend the nursing home admission. This program has now had certain restrictions included, to make it unsuitable for long term care.
That Medicare automatically covers up to 100 days of nursing is a myth. Not all nursing home patients are on Medicare. The patient may be below 65 years old, the hospital stay may not be of 3 full days or there may not be a proper reference by a doctor. Even when these conditions are present, Medicare provides full coverage only for the first 20 days.
Long Term Home Care by Medicare
Medicare is the main provider of health care to the American people. But since Medicare is not intended to provide long term care to the chronically ill elderly, care provided to patients in their homes through Medicare is presently restricted to the elderly patients recovering from acute (not chronic) medical conditions.
An Act of the Congress in 1996 known as the Health Insurance Portability and Accountability Act, together with the Balanced Budget Act, has restricted the availability of Medicare assistance to patients requiring home care to 60-day episodes. This has resulted in huge savings in the Medicare scheme. As per the Balanced Budget Act, Medicare payments for home care were doled out under the Prospective Payment System. Under this system the agency providing home care is reimbursed charges for a 60 day episode. This period can be reduced if recovery is early.
Long Term Care Through Social Health Maintenance Organizations
Social Health Maintenance Organization (SHMO) is an organization providing all the usual medical benefits plus prescription drugs, chronic care services and home care services like adult day care and homemaker services, for longer-term durations. The service offers extended care and other benefits such as eyeglasses, hearing aids, dentures and other dental benefits.
There are presently 4 SHMO sites participating in Medicare and each has their own eligibility criteria. Each site has different costs. All plans have co-payments for certain services. To obtain information, please visit the website of Medicare. It is recommended that, before making any health plan decisions, you should contact the plan directly.
Long Term Care Through Program of All Inclusive Care for the Elderly (Pace)
PACE combines the benefits of both Medicare and Medicaid to cater specifically to the long term care requirements of the elderly who may be frail and meet the criteria for nursing home care, as applicable in their State. This program offers comprehensive medical, surgical, nursing and home care facilities. The package allows elderly patients to continue living at home and receive requisite medical care. Medical services such as doctors, nurses and other medical professionals are available as one integrated plan. PACE is used in States that have opted to offer this program under Medicaid.
To qualify for this facility the recipient should be older than 55, be living in an area serviced by PACE, and be medically examined and found suitable by a team of doctors.
