Medicare Guide

• Skilled services must be reasonable and necessary for the condition which was treated during the hospital stay, or condition which arose in a skilled nursing facility while being treated for a condition which was previously treated in a hospital
  
  
• The skilled nursing facility must admit the patient within 30 days of hospital discharge and admission must relate to the condition that made the hospital stay necessary
  
  
• Days must be available in the current Benefit Period
  
  

Benefit Period
In a skilled nursing facility, Medicare Part A measures your use of services for a given time frame or Benefit Period. A Benefit Period begins the first day you receive services up to 100 days. Your Benefit Period ends on the last day of a 60-consecutive day period when you were not receiving Medicare-covered services or you did not have an inpatient stay at a hospital or a skilled nursing facility.
There is no limit to the number of Benefit Periods you may receive.

During a Benefit Period:

• Medicare coverage under Part A is available for up to 100 days of skilled nursing services or rehabilitation
  
  
• The first 20 days are fully covered by Medicare
  
  
• The remaining 80 days have a co-payment
  
  

Who is entitled to Medicare?
Medicare provides insurance coverage to individuals:

• age 65 and older
  
• who are disabled; and
  
• people with permanent kidney failure

There are special cases when people are not eligible, contact your Social Security Administration Office for more information.

You might not need 100 days of skilled services under Medicare. The physician and the nursing facility monitor your needs and decide if continuation of services covered by Medicare meets eligibility requirements.

Services that Medicare Part A helps to pay for while in a skilled nursing facility:

• semi-private room
  
• all meals, including special diets
  
• routine nursing services
• drugs, biologicals (vaccines, serums) and diagnostic services (x-rays, lab tests) provided by the nursing facility
• physical, occupational, speech and respiratory therapy
• medical supplies, appliance and certain equipment provided by the nursing facility
• medically related social services
• housekeeping and laundry medical services
• blood transfusions

Non-covered services

• non-skilled, or “custodial” care
• personal convenience items
• private duty nurses
• private room fees, except when a physician certifies that a private room is medically necessary

Eligibility Requirements
Medicare B is voluntary. Anyone entitled to Medicare Part A benefits can enroll in Medicare Part B. The program has a monthly premium, annual deductibles and coinsurances. Most United States residents who are age 65 or older can enroll in Part B coverage without having Part A.

Medicare Part B, often referred to as “outpatient: or physician’s insurance: helps pay for:

• physician services
• outpatient hospital services and certain medical supplies, drugs and biologicals (vaccines, serums)
• outpatient physical therapy, including occupational and speech
• diagnostic testing (x-rays and lab tests)
• durable medical equipment
• certain prosthetic services
• surgical dressings, splints and casts
• parental and enteral nutrition
• certain vaccines including Hepatitis B and Influenza (flu)
• Blood

• Routine physical examinations and related tests
• Routine podiatry services and dental care
• Examinations to prescribe or fit eyeglasses or hearing aids
• Most immunizations, prescription drugs or cosmetic surgery, unless needed because of accidental injury or to improve function