Long Term Care

Medicare and You

What is Medicare?
Medicare is a national health insurance program for people 65 and older, certain younger disabled people, and people with permanent kidney failure.

Medicare is divided into two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). Part A pays for care in a hospital and a skilled nursing facility, and for home health and hospice care. Part B helps pay doctor bills, and for outpatient hospital care and other medical services not covered by Part A.

Your Benefits Under Part A
Medicare Part A helps with the cost of medically necessary inpatient care in a hospital. If, after hospitalization, a stay in a skilled nursing facility like Stella Maris is required, Part A will also help with the cost. In addition, Part A also pays for home health care, Hospice care, and 80% of the approved cost for durable medical equipment supplied under the home health benefit.

MEDICARE HOSPITAL INSURANCE
(PART A) COVERED SERVICES

Services	Benefit		Medicare Pays		You Pay
Hospitalization Semiprivate room and board, general nursing and other hospital supplies and services	First 60 days		All but $760		$760
	61st to 90th day		All but $190 a day		$190 a day
	91st to 150th day		All but $380 a day		$380 a day
	Beyond 150 days		Nothing		All costs
Skilled Nursing Facility Semiprivate room and board, skilled nursing and rehabilitative services and other services and supplies.	First 20 days		100% of approved amount		Nothing
	Additional 80 days		All but $95 a day		Up to $95 a day
	Beyond 100 days		Nothing		All costs
Home Health Care Part-time or intermittent skilled care, home health aide services, durable medical equipment and other services.	Unlimited as long as you meet Medicare requirements for home health benefits.		100% of approved amount for services; 80% of approved amount for durable medical equipment		Nothing for services; 20% of approved amount for durable medical equipment
Hospice Care Pain relief, symptom management and support services for the terminally ill.	For as long as doctor certifies need.		All but limited costs for outpatient drugs and inpatient respite care.		Limited cost sharing for outpatient drugs and inpatient respite care.

Benefit Period
Part A benefits are paid on the basis of a benefit period. This period begins on the first day you receive a Medicare covered service as an inpatient in a hospital. The period ends when you have been out of the hospital or a skilled nursing or rehabilitation facility for 60 days in a row. After the 60 days, a new benefit period begins should you need to be hospitalized. At the time of your next hospitalization, your benefits are renewed and you must pay another deductible. There is no limit to the number of benefit periods you may have.

What is a skilled nursing facility?
It is a facility that provides skilled nursing and rehabilitation services. A skilled nursing facility is different from a nursing home, but may be a distinct part of one. Medicare will not pay for your stay at a SNF if the services you receive are primarily personal care or custodial.

How do I qualify for SNF services?
To qualify, you must:

• Require daily skilled care which can only be provided on an inpatient basis;
• Be in the hospital 3 consecutive days, excluding day of discharge.
• Be admitted to the skilled nursing facility for the same reason as the hospitalization.
• Be admitted to the facility within 30 days of your discharge from the hospital.

How do I qualify for home health services?
To qualify for home health coverage, you must:

• Require intermittent skilled nursing care, physical or speech therapy.
• Be confined to your home.
• Be under a doctor's care.

What are Medicare's Hospice benefits?
Medicare pays for hospice care for terminally ill persons who choose to receive hospice care rather than regular Medicare benefits for management of their illness. Under Medicare, hospice is primarily a program of care provided in the patient's home by a Medicare approved hospice. The focus is on care, not cure.

Medicare Medical Insurance Benefits
Medicare Part B covers many medical services and supplies. The most important benefit, however, is for your doctor bills. Regardless of where you receive them -- at home, in the physician's office, in a skilled nursing facility, or in a hospital -- medically necessary services of a doctor are covered by Medicare Part B.

MEDICARE BENEFITS AND CO-PAYS UNDER PART B

Services	Benefit	Medicare Pays	You Pay
Medical Expenses Physician's services, inpatient and outpatient medical and surgical services and supplies, rehabilitative therapies, tests, and DME	Unlimited services if medically necessary, except for the services of independent physical & occupational therapists.	80% of approved amount (after $100 deductible); 50% of approved amount for most outpatient mental health services; up to $720 a year each of independent physical and occupational	$100 deductible; 20% of approved amount after deductible; charges above approved amount; 50% for most outpatient mental health services; 20% of first $900 for each independent physical and occupational therapy and all charges thereafter each year.
Clinical Lab Services Blood tests, urinalysis and more.	Unlimited if medically necessary.	Generally 100% of approved amount.	Nothing for services.
Home Health Care Part-time or intermittent skilled care, home health aide services, durable medical equipment and supplies and other services.	Unlimited as long as you meet Medicare requirements.	100% of approved amount for services; 80% of approved amount for durable medical equipment.	Nothing for services; 20% of amount Medicare approves for durable medical equipment.
Outpatient Hospital Services Services for the diagnosis or treatment of an illness or injury.	Unlimited if medically necessary.	Medicare payment to hospital based on hospital costs.	20% of whatever the hospital charges (after $100 deductible).

More Questions?
Stella Maris provides skilled nursing care and rehabilitative services. Stella Maris can also provide hospice and home health care. If you need further assistance, call the Admissions Office at Stella Maris -- our staff will be glad to help you with your questions regarding coverage.

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