HOW MEDICARE WORKS
Medicare, a national health insurance program, serves individuals who are 65 and older, as well as certain disabled individuals. It is administered by the Center for Medicare (CMS) of the U.S. Department of Health and Human Services, with enrollments made through the Social Security Administration.
Essentially, the program has two components. Medicare Part A covers inpatient care in a hospital or sub-acute care facility as well as nursing home, home health and hospice services. Medicare Part B includes physician services, diagnostics and outpatient services. While Part A coverage is automatically available for those eligible for Medicare, Part B coverage is optional and must be purchased separately from Medicare through monthly payments.
In order to be eligible for Part A coverage:
The individual must be admitted to Southgate from a hospital, or from home as long as it is within 30 days of a hospital discharge, and used a minimum of three consecutive hospital days; The medical reason for admission to Southgate must be consistent with the medical reason for hospitalization.
The individual must be in need of daily skilled nursing care and/or daily skilled rehabilitative services – not custodial care. Custodial care typically encompasses services associated with long-term care facilities such as help with activities of daily living like feeding, washing and dressing. Medicare does not cover custodial or respite care.
NOTE: The maximum amount of time that Medicare will cover sub-acute or skilled care is 100 days. If, at any point during those 100 days, sub-acute care or skilled rehabilitative care is no longer needed on a daily basis or will not benefit the patient’s outcome despite continuing service, Medicare will stop coverage. An interdisciplinary team of health care professionals makes this determination.
Overall, Medicare’s role in coverage at Southgate works like this:
For the first 20 days, Medicare pays the full amount (provided the patient meets the criteria above)
Between the 21st and 100th day, the individual shares the cost with Medicare, paying approximately $157.50 per day co-payment (providing the patient meets the criteria outlined above); Patients may have a supplemental insurance policy which covers all or part of this co-payment. After the 100th day, the individual assumes responsibility for payment of the full amount.
HOW MEDICAID WORKS
Medicaid works somewhat differently, as it focuses on monetary assets rather than age. Southgate does accept Medicaid residents. Keep in mind, however, that does not mean we will have an opening for a Medicaid patient at the time someone is seeking placement. We do maintain a Medicaid waiting list and strongly encourage completing an admission application to start the process.
Because it is a federal/state program, eligibility requirements and services covered vary widely. Questions regarding Medicaid eligibility should be directed to your local Medicaid Unit.