Received a number of questions regarding Medicare and what types of services Medicare will pay for at home or in a nursing home. Many individuals who have reached the age of 65 are eligible for Medicare coverage. Individuals who have not yet attained the age of 65 are eligible for Medicare coverage if they have been entitled to Social Security Disability benefits because they have suffered permanent kidney failure and need maintenance dialysis or a kidney transplant or have been diagnosed with ALS or motor neuron disease. Long-term-care costs are covered by Medicare only to a very limited extent. Nursing Home Coverage Medicare provides very limited coverage for Skilled Nursing Facility care (SNF). Medicare covers skilled, not custodial care in a nursing home. In order to qualify for coverage, the Medicare beneficiary must be hospitalized for medically necessary in-patient care for at least three (3) consecutive calendar days for the same condition that is to be treated in the skilled nursing facility; they must be admitted to the nursing home and receive the needed care within thirty (30) calendar days after the date of discharge from the hospital; and they must require and receive daily skilled care. Nursing or skilled rehabilitation services are the most common qualifying services, but they are not mandatory for coverage purposes. The totality of the circumstances determines whether or not the care provided is skilled. The initial determination of coverage is made by the facility upon admission. If the Medicare beneficiary is not informed in writing that, in the opinion of the nursing home, Medicare will not cover the services, they have the right to assume that the services will be covered until written notice of non-coverage is provided. Without written notice of non-coverage, the nursing home cannot bill the patient. If the nursing home determines that, in their opinion, the services will not be covered by Medicare, they must allow the patient the option of submitting the services for reimbursement to Medicare. Pending determination of coverage by Medicare, the nursing home can not bill the patient. Many services are denied initially by the nursing home and Medicare, but are often approved upon appeal to an Administrative Law Judge. Vigorous advocacy can often obtain up to 100 days of nursing home care coverage under the Medicare program. Days 1-20 in the SNF are fully covered if the care is qualified as outlined above. Thereafter, for days 21-100 there is a co-insurance payment of $99.00 (in 2001) per day. Home Care Coverage Additionally, Medicare beneficiaries can receive, in theory, an unlimited number of home health care visits without deductibles or co-insurance if the following conditions are met: the beneficiary requires and receives skilled intermittent nursing, or physical, occupational or speech therapy; the beneficiary is homebound; and a physician certifies the need for home health care. Realistically, home health aide benefits are usually limited to five days a week for four hours a day for a short period of time. ALS patients normally do not qualify for skilled services as Medicare views the needs as custodial. Medicare-supported home care is therefore a limited benefit for ALS. Medicare Supplement Insurance - Medigap Medicare supplemental policies, often referred to as "Medigap" policies, should be purchased by all Medicare recipients. Federal law requires that all "Medigap" policies be one of ten standard options. It is advisable that seniors avoid plans A and B, which do not cover the co-payment for days 21 through 100 in a nursing home. Medicare Managed Care In certain geographical areas, there may be Medicare managed care options which are available to a patient as an alternative to Medicare fee-for-service. Most of these are Health Maintenance Organizations (HMOs), but there are other options available under the Medicare law. If a patient elects managed care, they are agreeing to limit themselves to certain providers and to obtain prior approval for most services in exchange for expanded coverage. These plans avoid the need for Medigap insurance, provide expanded coverage, and they are especially attractive to healthy individuals . However, there are numerous published reports of problems resulting from denial of services. Therefore, if a patient has major medical needs or particular providers they wish to have access to, they should select the traditional Medicare fee-for-service plan. Remember, a patient can always switch from managed care back to Medicare fee-for-service the next month. However, they may not be able to obtain Medigap insurance or may have to pay a premium for obtaining coverage. The rules for obtaining skilled home care or skilled nursing care are the same in the Medicare managed care arena. However, a Medicare managed care member will not be able to enter a nursing or rehabilitation facility that does not have a contract with that particular policy. Thus, being a member of a Medicare managed care plan may limit a Medicare beneficiary’s access to the nursing facility of their choice. You should send your questions by mail to "Ask the Attorney", c/o of Sheryl R. Frishman, Esq., Freedman and Fish, LLP 521 Fifth Avenue, 25th Floor, New York, New York 10175 or via E-mail to SFrishman@freedmanandfishllp.com. Please note that the answer to any of your questions is not the rendering of legal advice, and an attorney should be consulted before relying on any of the information given in this column.