Glossary of Medicare Terms To Know
Following is a list of definitions of terms used by Medicare:
The way that Medicare measures your use of hospital and skilled nursing facility services.
A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row.
If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.
Any unused days in one benefit period will NOT carry over to the next. You simply get another 60 days.
For example, if you go into the hospital and stay 55 days and you go back into the hospital within sixty days of leaving the hospital, you will not have to pay another hospital deductible, but you will only have 5 days remaining of the 60 days that Medicare pays in full. If, however, you return into the hospital 75 days after leaving the first time, you will have a full 60 days of full coverage, but you also must pay another hospital deductible.
The percent of the Medicare approved amount that you have to pay after you pay the deductible for Part A and/or Part B. In the Original Medicare Plan, the coinsurance payment is a percentage of the cost of the service, such as 20%.
In some Medicare health plans, the amount that you pay for each medical service you get, like a doctor visit. In the Medicare program, a copayment is usually a fixed amount you pay for a service, such as $5.00 or $10.00.
The amount you must pay for health care, before Medicare begins to pay.
There is a deductible for each benefit period for Part A, and each calendar year for Part B. The deductible amounts change from year to year.
Home Health Care
To be covered by Medicare, your doctor must certify that you meet the eligibility requirements for coverage and specify specific skilled services, their frequency and the duration of care needed. All covered services must be provided by a Medicare-Certified Home Health Agency.
To qualify for the Medicare home health benefits, you must meet the following criteria:
- Have either Medicare Part A or Part B
- Be homebound. (Leaving home must require a considerable and taxing effort.)
- You must require either:
- Skilled therapy services or
- Skilled nursing on a part time or intermittent basis. Part time is fewer than 8 hours per day for periods of 21 days or less. Intermittent is skilled nursing provided fewer than 7 days per week.
- You must be certified by your doctor as meeting the requirements for eligibility in a letter specifying the services needed and their frequency and duration.
Upon receipt of your doctor's certification letter, a Medicare-Certified Home Health agency will send a nurse to evaluate your needs and determine a plan of care.
If you are approved for benefits, you may receive skilled nursing and home health aide service up to 7 days per week as long as services do not exceed 8 hours a day and 35 hours a week. Additionally, you may receive skilled therapy services and medical social services.
Types of services available through Home Health and the requirements for them include:
- Skilled Services. The services required must be reasonable and necessary and so inherently complex that a skilled nurse or therapist must perform or supervise them in order to be safe and effective. A service is not considered to be "skilled" if a home health aide or other person could perform the service.
- Skilled Nursing. The skilled care of a registered nurse must be reasonable and necessary to the diagnosis and treatment of your illness or injury. Examples of covered services include:
- Administration of medications.
- Tube feedings, catheter changes and wound care.
- Teaching and training activities.
- Observation and assessment of a patient's condition.
- Management and evaluation of a patient's care plan.
- Skilled Therapy. Physical, speech and occupational therapy services are covered up to the limits shown in the charts above. To receive coverage for occupational therapy, however, you must need it initially in conjunction with physical or speech therapy.
- Home Health Aide Services. Aide services include personal care such as bathing, feeding, dressing and toileting services. Medicare does not cover housekeeping services, such as cleaning and cooking.
- Medical Social Services. Social services help patients and families deal with the logistics and emotional issues related to the illness.
- Medical Supplies. A home health agency will provide whatever supplies are required for nurses to do their duties except for medications.
NOTE: The need for skilled care must be present in order to receive the services of a Home Health Aide. You cannot receive the services of a Home Health Aide only.
Whether your condition is acute, chronic or terminal, you should continue to receive the benefit indefinitely as long as you continue to be homebound and to have a need for skilled care. For example, patients with multiple sclerosis requiring maintenance therapy should continue to receive Medicare-covered home health care as long as they meet eligibility requirements.
Lifetime Reserve Days
In addition to the days of coverage provided by Medicare during any benefit period, Medicare provides an additional 60 days in case you are in a hospital for more than 90 days. These 60 reserve days can only be used once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance (of $550 in 2010.)
Like most health plans, Medicare only covers medical charges that are deemed to be Medically Necessary. Medicare defines Medically Necessary as Services or Supplies that meet all of the following criteria:
- Are proper and needed for the diagnosis, direct care or treatment of your medical condition. This means:
- The charge must relate to a medical condition that you have or may have. Medicare won't cover an annual physical, but it will cover a complete physical exam if you have a symptom such as fatigue or pain.
- Any preventive charges not specifically listed and other charges unrelated to a medical problem are not covered.
- Meet the standards of good medical practice in the medical community of your local area. This means that unless the treatment is generally recognized by physicians as appropriate treatment for your particular condition, it is not covered. This can be an issue if your doctor is a recognized leader in his or ld and uses innovative or cutting edge treatments.
- Are not mainly for the convenience of you or your doctor. This means that Medicare doesn't pay for extra hospital days, use of ambulance for convenience rather than necessity, and other voluntary procedures or treatments.
Medicare Approved Amount
Medicare determines the maximum amount that it will pay. Medicare sets the amount based on the geographical area and the expertise of the service provider. It is generally less than a doctor would normally charge but not so low that it discourages doctors from accepting Medicare beneficiaries as patients.
Power Operated Vehicles (Electric Wheelchairs and Scooters)
All electric mobility scooters, as well as motorized wheelchairs, potentially qualify for Medicare as a power operated vehicle (P.O.V.).
Medicare, has some basic requirements before even considering any type of reimbursement. They are as follows:
- A POV (electric scooter) is usually covered only if it is ordered by a doctor who is a specialist in one of the following areas:
- Physical Medicine
- Orthopedic Surgery
- The individual is unable to operate a manual wheelchair.
- The individual is able to operate the scooter and is stable enough to transfer in and out of the scooter safely.
- The individual's condition must be such that a POV is required for the patient to get around in his or her residence.
Skilled Nursing Facility (SNF)
A Skilled Nursing Facility (SNF, pronounced "sniff") is a facility that specializes in skilled care. It has the staff and equipment to provide skilled nursing care or skilled rehabilitation services and other health related services. A person is placed in a SNF when there is a need for ongoing medical care but not enough to require confinement in a regular, acute-care hospital.
To qualify for SNF benefits under Medicare Part A, you must meet all of the following requirements:
- You have been in a hospital at least three days in a row (not including the day of discharge) before you enter the SNF.
- You enter the SNF within a short time (usually 30 days) after you leave the hospital.
- Your care is for an illness that was treated in the hospital. Your care also could be for an illness that arose when you were in the SNF for an illness treated in the hospital.
- You require daily skilled nursing or skilled rehabilitation services that you can only receive in a SNF. This must be certified by a doctor, nurse practitioner or clinical nurse specialist.
Also, for Medicare to cover you in a SNF, it must be a SNF that is approved by Medicare.
To ensure coverage, make sure your physician pre-certifies your SNF stay.
Medicare does not cover care that is considered to be "custodial" in nature whether it is in a nursing home, SNF or other type of facility. Custodial care is care that consists primarily of assisting the patient with Activities of Daily Living such as feeding, going to the toilet, bathing and walking as opposed to active medical care to improve or maintain one's health. See Medicaid -- Nursing Home Coverage.
There are quality standards that every SNF must meet, including:
- A SNF cannot make you pay anything to be admitted unless it is clear that Medicare does not cover the cost of services.
- You must be told right away if the SNF decides you do not need the level of skilled care covered by Medicare. If you disagree with this decision, you may ask that the SNF submit something called a "demand bill" to Medicare.
- A Demand Bill is a claim a SNF may file with Medicare before services are actually rendered so that Medicare can determine in advance whether or not they will cover the charges.
- The SNF must submit the demand bill and cannot make you pay a deposit for services that Medicare may not cover until Medicare gives its decision.
- You must pay for any coinsurance while the demand bill is being processed, and for services not covered by Medicare.
Questions about Skilled Nursing Facility Care should be directed to the Fiscal Intermediary that handles your state. For a list of them see Medicare and You 2013 or The Guide to Choosing a Nursing Home available from Medicare at 1.800.MEDICARE (800.633.4227) or on the Internet at www.medicare.gov .
When your Medicare Part A benefits for SNF end, there are certain Medicare Part B services that can continue to be covered. Services which can continue to be covered include:
- Laboratory tests
- Medical supplies
- Physical therapy
- Occupational therapy
- Speech therapy
- Specialty drugs like Hepatitis B vaccine, influenza and PPV vaccines, certain oral anti-cancer drugs and immunosuppressive drugs.
Hospice is a special way of caring for people who are terminally ill, and for their family.
To learn more, see: Medicare: Hospice Care.
- For details about the Original Medicare claims process, see Medicare -- Claims Advice.
- For a glossary of words relating to: