During an injury, or leading up to surgery or retirement, many people begin to wonder about the true value of the benefits they receive from the U.S. Government. Those benefits come primarily in the form of Social Security, Medicare, and Medicaid, which are social and health programs designed to care for the elderly and those unable to care for themselves. As you get older, you might consider expensive surgeries or retirement options you’ll need to use Medicare or other coverage to pay for.
Many people have questions about what Medicare is and what it covers. Check out our post covering what Medicare is for detailed information, but in short, Medicare is composed of four different “parts” known as Parts A, B, C, and D. Each part of Medicare provides different health care coverage, so it’s important to know the difference, and if you’re covered.
Separate from Medicare is Medicaid, which focuses primarily on providing additional health care for low-income Americans. Medicaid’s income requirements are stringent, and states can distribute funding based on their own rules (unlike Medicare), but it can come in handy when seeking health care or daily care. You can learn more about transferring Medicaid to a different state from our Guide on Moving to Florida for Assisted Living.
To receive Medicare, you must be age 65 or older, have a disability, or suffer from End-Stage Renal Disease. Other exceptions exist, but Medicare is generally reserved for seniors.
Below are some very common health care facilities and services you may think about during retirement or leading up to surgery, and whether Medicare covers them or not.
Hospital Care and Emergency Services
Medicare covers inpatient hospital care under Part A if a doctor gives an order determining that you need inpatient hospital care to treat your injury or illness, and the hospital does or will accept Medicare. This includes a typical setup of a semi-private room, your meals, your general nursing needs, and the drugs and services necessary to heal your injury or illness.
Part B of Medicare functions roughly like health insurance, and covers emergency procedures, including ambulance services. You are responsible for a copayment and 20 percent of the amount Medicare pays for your emergency services, including your deductible.
Home Health Care
Medicare pays for home health care under Part A and Part B. Medicare’s coverage of home health care includes part-time skilled nursing care, physical therapy, occupational therapy, speech-language pathology services or speech therapy, and medical social services.
To receive home health care, your doctor must certify you’re homebound, under their plan of care, and able to recover from a condition or maintain your health with the help of a skilled therapist.
Under Medicare, home health care services cost you nothing. However, similar to the Part B rules above, you’re on the hook for 20 percent of the cost for durable medical equipment (DME), like a walker or wheelchair. Depending on your doctor, other insurance, and other variables, your costs may be higher or lower for home health care.
Skilled Nursing Facilities
Part A of Medicare pays for skilled nursing care in a skilled nursing facility (SNF), but there are a few rules. Typical services Medicare covers at a skilled nursing facility include a semi-private room, meals, skilled nursing care, therapies needed to meet your health goals, medication, medical social services, and dietary counseling. If you need other services, talk to your health care provider and personal insurance about your coverage.
Your skilled nursing coverage lasts for a limited time and only if you meet these conditions:
- You’re covered by Part A and have days left in your “benefit period”, which begins the day you’re admitted into a hospital or SNF as an inpatient
- You have a qualifying hospital stay for surgery or treatment lasting three days
- Your doctor decides you need skilled care provided or supervised by skilled nursing or therapy staff
- The skilled services you need are for a hospital-related medical condition or a condition that began during your care
Medicare Part A covers the first twenty days of your stay in any given benefit period and charges you $170.50 coinsurance per day up to Day 100. After that, you’re charged all costs.
So Medicare Part A and Part B do a pretty good job of providing for your health care at hospitals, in emergencies, and in skilled nursing situations. There are a few other considerations many seniors have outside the hospital and recovery settings, including prescription drugs, hospice, and assisted living. If you’re here, you’re probably focused on that last one, and we’ll get there soon!
Medicare pays for prescription drugs under Part D. Drug coverage is an optional component of Medicare when you enroll. Prescription drugs are also often covered by Medicare Advantage Plans — Part C, popularly run by health maintenance organizations (HMOs) and preferred provider organizations (PPOs) — which bundle the services offered by Medicare plus other benefits.
Prescription drugs are an important part of drug therapy. If you’re staying at a skilled nursing or assisted living facility, it’s likely they’re partnered with a closed-door, long term care pharmacy that helps fill, review, and manage your medication.
If you’re over the age of 65, Medicare generally covers any prescription drugs you may need until you reach $3,820, known as the coverage gap. From there, you’re required to pay more towards your prescriptions until you exit the coverage gap, but there are ongoing changes to this aspect of Medicare you can read more about on the Medicare website.
Medicare pays for hospice care under Part A. If your hospice doctor and primary care physician certify you’re terminally ill, you elect to accept palliative care — care for comfort and reducing pain, rather than for a cure or treatment — and you sign a statement choosing hospice rather than another Medicare-covered service, you will receive covered hospice care in your home or at an end-of-life facility like a nursing home or another specializing in end of life care.
But what if you or your loved one don’t fit into any of the categories above? You might need more help than your normal for weeks or months following an injury, have daily issues with normal activities like walking or bathing, or simply prefer a better social setting. An assisted living facility may be right for you.
Assisted Living Facilities
Medicare does NOT pay for assisted living facilities or continuing retirement communities. Long-term housing and care like what you’ll find at an assisted living facility are funded out of pocket using retirement assets, with long term care insurance, veterans benefits, or by selling assets like your home, which you may no longer need. Medicare focuses only on providing short-term skilled health care services to seniors who need it.
However, this is where Medicaid comes in.
If you have limited assets, you could qualify for the Statewide Medicaid Managed Care Long-Term Care Program, a “nursing home diversion program” managed by the state of Florida under the federal Home & Community-Based Services (HCBS) Waiver Program. Contact your local Aging and Disability Resource Center for more information on how to apply.
Even with a Medicaid waiver, ALFs can still be expensive. Angels Senior Living operates two communities for low-income residents, Palm Terrace Assisted Living and Adult Day Care, and Hacienda Villas. Several other Angels Senior Living communities are also quite affordable compared to typical monthly costs, which can range upward of $6,000.
What Health Care Services Are Right for Me?
There is no set path to a happy and healthy lifestyle for you or your loved one in advanced age. Your own health goals and advice from your doctor are key to finding what’s right for you. If that’s assisted living, our senior living advisors are happy to help you find the perfect fit! Give us a call at 877-480-2244 for more information.