Medicare coverage

Experience recently taught us more about Medicare coverage after hospitalization. For review: At www.medicare.gov, you find that “Medicare is a health insurance program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease …” It’s a federal program administered by the states. If you qualify for Medicare, Part A covers hospitalization, Part B covers medical insurance such as doctors’ visits, and Part D is prescription drug coverage. Part A is our focus this month.

Factored into who pays what in the event of hospitalization are length of stay and “benefit periods,” which begin whenever you are hospitalized and end when you have been out of the hospital or skilled nursing care for 60 days. In 2008, each benefit period deductible is $1,024, meaning that Medicare pays all but $1,024 for the first 60 days of hospital care.

Suppose you: have a Medicare-covered hospital stay beginning March 1 for 30 days; return home April 1 for 60 days; have to reenter the hospital on May 31 (day 61). You’ll owe a deductible for each stay.

After 60 days, a patient co-pay of $256 per day from 61 to 90 days applies. (Beyond 150 days, Medicare pays nothing.) Then, as part of your Part A “benefit period,” if you need skilled nursing skill for rehabilitation after hospitalization, Medicare pays 100 percent of the approved amount for the first 20 days. The next 80 days will cost you (or your Medicare supplemental insurance provider) $128 per day. After 100 days, your nursing home care is your responsibility.

Here’s the catch: Your Medicare coverage is contingent on administration of the skilled nursing care that’s being provided because of your hospital stay. Recently my 94-year-old mother-in-law was not progressing in the physical therapy (PT) prescribed to recover from hospitalization for near-fatal pneumonia. We thought her Medicare coverage was based on a range of nursing services that she needed. Though we knew the PT would end if it wasn’t successful, we didn’t know Medicare eligibility would also end, because the PT was the only Medicare-qualifying service being provided.

For instance, she was also receiving insulin for diabetes that had been triggered by the lung infection, but we learned that the patient and family are considered capable of administering insulin. Therefore insulin is not justification for continued Medicare eligibility.

In this case, we were given the standard 48 hours notice that the nursing home care ($264 per day, or $7,920), would be payable privately and though we appealed to the Medicare oversight body, the ruling was unfavorable.

Bottom line: Know the hospital and nursing home charges and all details of Medicare coverage.