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medicare & long term care

It's crucial to differentiate between Medicare and Medicaid, as many families mistakenly believe that Medicare, the insurance for those aged 65 or older or those determined disabled under Social Security rules, will cover long-term care needs. Medicare is not designed to be a safety net for long-term care, and this often comes to light during acute medical events, where families discover that Medicare offers limited coverage for skilled nursing facility care.

One common issue is "Observation Status." When a Medicare enrollee is in the hospital, they may receive various tests and evaluations but are not actually admitted. Instead, they are classified under observation status. This distinction is significant because it affects how Medicare benefits are applied. If you are officially admitted to the hospital, Medicare Part A covers your stay. However, if you are under observation, Medicare Part B and Part D come into play, which may involve more cost-sharing and higher out-of-pocket expenses. To qualify for up to 100 days of Medicare-covered rehab in a skilled nursing facility, a patient must have a minimum three-day hospital stay. Observation status does not count towards this requirement, potentially leaving patients without the necessary coverage.

To avoid these issues, always check whether you or your loved one is admitted or under observation status. Your family doctor may assist in explaining why hospital admission is necessary. There are also new appeal rights if your status is retroactively changed from admitted to observation. For more information, the Center for Medicare Advocacy provides a comprehensive toolkit on observation status.

Another frequent issue arises around day 20 of a stay in a skilled nursing facility when patients are often told they have "plateaued" and no longer qualify for additional rehab benefits under Medicare. However, it's important to know that you have the right to appeal decisions regarding the termination of benefits. The law states that Medicare’s 100-day benefit can be used to maintain a patient's condition, not just improve it. The Center for Medicare Advocacy offers resources and toolkits to help you navigate these challenges. They have successfully maintained a class action lawsuit prompting CMS (Centers for Medicare & Medicaid Services) to provide educational content for providers, ensuring they understand that Medicare benefits are also meant to maintain a patient's condition.

Medicare can offer significant benefits, but it is not designed to cover long-term care for chronic illnesses. Knowing how and when to advocate for the benefits you are entitled to is essential. For further resources and support, visit the Center for Medicare Advocacy's website. By staying informed and proactive, you can better navigate the complexities of Medicare and ensure you or your loved one receives the necessary care.

When you find yourself overwhelmed, it can be challenging to determine where to begin. The key is to focus on doing what really matters most. To help you get started, we have broken down the process of reaching out to us and then completing your legal work into manageable steps, providing guidance every step of the way. 

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