What Does Medicare Cover?

Q: I will be 65 soon and will be going on Medicare. What will it cover now and in the future for my healthcare needs short or long term?

A: The Medicare program is jointly administered by the state and federal government. Medicare is available to adults 65 years of age and older, or those under the age of 65 entitled to Social Security Disability. Medicare provides varying levels of medical coverage, depending on the plan you have. Medicare Part A and Part B, two of the more basic plans, provide coverage for hospitalization stays, rehabilitation, physical therapy, routine doctor visits, and medical equipment. Medicare Part A will also cover the cost of hospice care with a terminal diagnosis of less than 6 months.

It is important to note that Medicare will not pay for long term care in a facility or services received at home on a long-term basis. For example, if you fall and require surgery, you may need rehabilitation in a facility before you're able to safely return home. As long as you meet all the requirements following the hospital stay, Medicare Part A will cover the full cost of the first 20 days in a rehabilitation facility. For days 21-100, there is a co-pay per day if the patient continues to need rehabilitation services. If you have a supplemental insurance policy or commonly referred to as a “gap” policy, this may help ease the cost of the daily out of pocket co-pays. After Medicare stops paying, the full cost of the nursing home falls on the patient. This can cost upwards of $600 per day.

As you can see, coverage for rehabilitation under Medicare Part A is intended to be short-term. The goal is improvement of acute conditions through rehabilitation and skilled nursing care. While given up to 100 days, patients rarely qualify for this full amount. After admittance to a facility, the patient is evaluated periodically. Once the facility determines that the patient no longer needs skilled care, coverage under the Medicare program ends.

The most important piece to understand is the difference between skilled care and custodial care. Medicare does not cover custodial care. There are many circumstances where the patient does not fall into the category of needing rehabilitative or skilled care, but the family cannot bring their loved one home. Anyone leaving a rehabilitation facility must have a safe discharge plan.

Medicare does not pay for time to set up a discharge plan. Once Medicare terminates coverage, the patient needs to return to the community or start privately paying for care.

As you enter the arena of Medicare during these unpredictable times, education is key. It is important to meet with your Elder Law attorney to discuss future care plans and options for aging in place successfully.

Britt Burner, Esq. is a Partner at Burner Law Group, P.C. focusing her practice areas on Elder Law and Estate Planning. Burner Law Group P.C. serves clients from Manhattan to the east end of Long Island with offices located in East Setauket, Westhampton Beach, New York City and East Hampton.