Medicare Practice: a Primer
| Jurisdiction | United States,Federal |
| Citation | Vol. 24 No. 8 Pg. 1789 |
| Pages | 1789 |
| Publication year | 1995 |
1995, August, Pg. 1789. Medicare Practice: A Primer
Much emphasis in the field of elder law is placed these days on knowledge surrounding the Medicaid program, right-to-die issues and issues of mental capacity. However, the majority of senior citizens may never face these issues. By contrast, the Medicare program affects almost all elderly persons in this country. Knowledgeable elder law practitioners must be in a position at least to advise clients in this area and should be able to provide a full range of advocacy, if necessary.
Medicare is a federal program established under Title XVIII of the Social Security Act that provides health insurance to certain groups of people at minimal or no cost. Generally, individuals are eligible when they reach the age of sixty-five and are eligible for Social Security retirement or survivor's benefits. Individuals also are eligible, regardless of age, if they have received Social Security disability benefits for at least twenty-four months.(fn1)
Few disputes arise with Medicare administrators regarding an individual's actual eligibility for the Medicare program. Instead, most problems concern whether a specific medical service to be provided to a client is a covered benefit under Medicare law. This article addresses these coverage issues and gives specific information as to the administrative and judicial appeals processes.
Medicare is divided into two primary coverages, Part A and Part B. Part A is frequently referred to as "hospital insurance" and generally covers all inpatient hospital costs, some nursing facility care and some care in the home. Part B is known as "medical insurance" and covers most outpatient care, including physicians' services, various therapies and durable medical equipment. The receipt of Part A benefits can be obtained merely by satisfaction of the requirements discussed above. Part B benefits, by contrast, require the payment of a monthly premium in order to become eligible. The amount of this premium changes each year. (It is $46.10 monthly for 1995 and is usually deducted automatically from the individual's Social Security benefits each month.) Part A and Part B are each subject to differing deductibles and "coinsurance" amounts, which are amounts a Medicare beneficiary must pay to the provider after the deductibles are satisfied.
The discussion of coverages listed below is not meant to be exhaustive. Practitioners are advised to refer to the Commerce Clearinghouse Medicare and Medicaid Guide for specific information regarding all coverages available under both Parts A and B.
The Part A deductible changes each year. For 1995, it is $716. A deductible is payable each time an individual suffers from a new "spell of illness." A spell of illness begins on the first day an individual is an inpatient of a hospital or skilled nursing facility ("SNF"), and ends on the sixty-first day after discharge from a hospital or SNF. Thus, the law allows an individual to pay more than one Part A deductible each year. Note that the spell of illness is not prolonged if the individual remains in a hospital or SNF but receives only custodial care, as opposed to an acute or skilled nursing level of care.(fn2)
After payment of the deductible, Medicare pays for the first sixty days of hospitalization and a portion of the cost for the next thirty days. The beneficiary is responsible for a coinsurance payment for this latter period ($179 daily for 1995). An additional "lifetime reserve" of sixty days is available for hospital stays in excess of ninety days, but a larger coinsurance amount is required to be paid by the beneficiary ($358 daily for 1995). Once the lifetime reserve is exhausted, benefits are limited to the first ninety days of hospitalization. Of course, a new ninety-day period begins each time an individual begins a new spell of illness.
Medicare coverage under Part A for inpatient hospitalization is severely limited by the concept of "diagnosis related groups" ("DRGs"). DRGs are an attempt by the Health Care Financing Administration ("HCFA") to limit the cost of the Medicare program by changing the manner in which hospitals are reimbursed for Medicare-covered expenses.
The old system of reimbursement was based on actual costs incurred by the hospital
The issue on appeal would be whether continued hospitalization is "reasonable and necessary" for the diagnosis or treatment of illness or injury. Indeed, Medicare coverage for all services in any category must satisfy this requirement.(fn7) Most important in prevailing on this issue is the opinion of the individual's treating physician.
To qualify for Medicare SNF coverage, an individual must have been an inpatient at a hospital for at least three days, and then transferred to an SNF within thirty days of the date the person was discharged from the hospital.(fn8) An individual can receive up to twenty days of SNF coverage under Medicare without payment of a deductible or coinsurance. A coinsurance payment is required for the twenty-first through the 100th days of SNF care. The coinsurance payment is set at such a level ($89.50 a day for 1995) that individuals receiving SNF coverage in Colorado must essentially pay the same rate to the nursing home as persons already completely on a private pay basis. (In Colorado, the average cost of nursing home care on a private pay basis as of December 1994 was approximately $89.17 a day.)
In addition to the limited number of days for which coverage is available, the availability of Medicare coverage of SNF care is further limited by the fact that such coverage is not available unless the individual requires skilled nursing care on a daily basis.(fn9) This is a fairly high level of care. Many nursing home residents either require an...
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