This week I will provide information about Medicare Part A and Part B, since these are the primary insurance payers for seniors.

As I mentioned in part 1, Part A is automatically given to persons 65 years of age. This part of Medicare covers inpatient hospitalization, skilled nursing facilities, home health care and hospice. That is a general statement because it only covers skilled care in a rehabilitation facility or home health when certain criteria have been met.

Families are generally unaware that Medicare Part A requires a minimum hospital stay of 3 days before they will cover any care in a rehabilitation or skilled nursing facility. If a beneficiary has met the minimum inpatient hospitalization Medicare will cover up to 20 days in a skilled facility. The patient will then be responsible for $128/day for days 21-100. After 100 days patients must pay 100%. If a patient has not been hospitalized for at least 3 days, Medicare will not pay anything for a rehab or nursing facility.

Medicare will pay for Home Health Care following a change in health status, or discharge from the hospital. To obtain Home Health, you need a physicians order, you must be homebound, and in need of skilled services such as a nurse or physical therapy. Home Health is temporary and limited by Medicare guidelines. It is based on a 60 day certification period.

If Home Health is ordered by the physician it will be set up based on 60 days of intermittent visits. The criteria of what care can be received is very strict, and the goal is to decrease visits toward the end of the 60 day period. Some patients may be re-certified for an additional benefit period, but the physician and Home Health professionals must prove an ongoing need. Just as Home Health can be extended, it can also be cut short.

Hospice is covered by Medicare Part A if criteria are met and a physician orders it. There is a lot of misunderstanding about hospice. I find this throughout the healthcare field. Most people and doctors think that you must have an expected life span of 6 months or less. Although that is a general guideline, Medicare has specific criteria that could qualify someone for hospice, without an actual terminal diagnosis.

The criterion is quite lengthy, so I will cover hospice in a future blog. For now I just want people to know that Alzheimer’s patients can qualify for hospice if they have a secondary qualification, such as significant weight loss, or have had a major illness or injury on top of an Alzheimer’s diagnosis. Most families don’t know that. Too many people get hospice much later then they should to receive all the wonderful benefits and support they provide.

I am a big proponent of hospice. I worked as a hospice nurse many years and families were always extremely appreciative for the team that assisted them through the most difficult time of their lives.

Medicare Part B is optional. It requires a premium from the insured but is a portion of the actual cost, approximately 1/3. Part B covers physician services in and out of the hospital, lab tests, some medical equipment, medications that cannot be self administered, most medical supplies, diagnostic tests, such as MRI’s, or CT scans, ambulance, outpatient and ambulatory surgery, some therapy, and blood infusions not covered by Part A. It will not cover any of these it doesn’t deem as medically necessary.

I have a problem whenever insurance states they will only cover this or that which is medically necessary. That leaves “medically necessary” up to interpretation. I have seen patients receive huge bills because the way the physician or hospital documented the problem didn’t fall into the medically necessary category.

You have the right to appeal any denial of Medicare payment. If you receive bills for services you feel should have been covered you can find information on appealing at www.cms.hhs.gov/MMCAG

I hope this clears the difference between Medicare Part A and B. Stay tuned each Thursday for the continuation of “Who pays for what?”

Angil Tarach has cared and advocated for seniors for over 30 years. She is the owner and director of Visiting Angels in Ann Arbor for the last 7 years. To contact her with questions or comments, she can be reached at visitingangelswc@comcast.net, or at (734) 929-9201