ABA Family Legal Guide

The Rights of Older Americans

Health and Long-Term Care Benefits

Medicare

What does Medicare Part A (hospital insurance) cover?

Part A helps pay for medically necessary hospital care, skilled nursing care, home health care, and hospice care as described below.

Hospitalization - This includes:

• a semiprivate room and board;
• general nursing;
• the cost of special-care units, such as intensive care or coronary care units;
• drugs furnished by the hospital during your stay;
• blood transfusions;
• lab tests, X rays, and other radiology services;
• medical supplies and equipment;
• operating and recovery room costs; and
• rehabilitation services.

Skilled Nursing Facility Inpatient Care Following a Hospitalization of at Least Three Days-- Your condition must require skilled nursing or skilled rehabilitation services on a daily basis, which, as a practical matter, can be provided only in a skilled nursing facility. You must be admitted within a short time (usually 30 days) after you leave the hospital, and the skilled care you receive must be based on a doctor's order. Most nursing-home residents do not require the level of nursing services considered "skilled" by Medicare. Consequently, Medicare pays for relatively little nursing home care. In addition, not every nursing home participates in Medicare or is a skilled nursing facility. Ask the hospital discharge staff or nursing-home staff if you are unsure of the facility's status.

Home Health Care -- Medicare covers part-time or intermittent skilled nursing care; physical, occupational, and speech therapy services; medical social services; part-time care provided by a home health aide; and medical equipment for use in the home. However, the benefit does not cover general household services.

To be eligible for home health-care services you must meet four conditions:

1. You must be under the care of a physician who determines you need home health care and sets up a plan.

2. You must be "homebound," although you need not be bedridden. An individual is considered homebound if leaving home requires a considerable and taxing effort and if any absences from the home are either for medical care, to attend adult day care or religious services, or are infrequent or for periods of relatively short duration.

3. The care you need must include intermittent skilled nursing, physical therapy, or speech therapy.

4. Your care must be provided by a Medicare-participating home health-care agency.

Hospice Care -- A hospice is an agency or organization that provides primarily pain relief, palliative care, symptom management, and supportive services to terminally ill people. Hospice services may include physician or visiting-nurse services, individual and family psychological support, inpatient care when needed, home health aide care, medications, medical/social services, counseling, and respite care for family caregivers.

To be eligible for hospice care, a patient must have a doctor certify that he or she is terminally ill (defined as a life expectancy of six months or less); the patient must choose to receive hospice care instead of standard Medicare benefits; and the hospice must be a Medicare-participating program.