Sitterley Law, LLC
Medicare

Medicare Coverage And The Law

The most important things to know about Medicare long term care coverage are the limitations, based on the plans you have selected. Typically, Medicare Plan A covers the first 20 days of hospitalization and long-term care/rehabilitation, so long as it is first triggered by a three-night stay in a hospital. Please note that the hospital stay must also be as an admitted patient, NOT just “under observation.”

After the first 20 days, depending on the plan you have, Medicare will cover an additional 80 days, subject to a co-pay, so long as the medical professionals involved believe the patient can continue to benefit from the care provided. There is no longer a requirement for the patient’s “continued improvement” in order to continue Medicare’s coverage during that time period.

If, however, medical providers determine an individual is no longer eligible to receive Medicare coverage sooner than 100 days, they must provide written notice three days prior to terminating said coverage. At that point in time, the individual may appeal the finding, may private pay, and/or may apply for Medicaid coverage.

Medicare Coverage: What To Expect

  • Appealing a Medicare termination of coverage: Since the notice is provided only 3 days before termination, you must act quickly if you intend to appeal.

  • Private pay: Depending on the facility and type of care needed, there is a wide range of daily rates between facilities and in-home care.

  • In Fairfield County, you can expect $20/hour to be a competitive rate among home health care providers. For assisted living facilities, the monthly rates can vary between $2,500/month and $7,500/month, depending on the level of care provided. In skilled nursing facilities, the average private pay rate in Ohio is currently $6,570/month.

  • Medicaid Eligibility: Often, a facility will offer to complete a Medicaid application for you, however, we do not recommend accepting this assistance if there is a possibility that you are not medically and financially eligible, since it will delay your coverage and potentially trigger a penalty period for a prior gift, or the establishment of a Medicaid planning trust, in the past 5 years. If there is a possibility that you have assets to protect or you have gifted any titled assets in the 60 months prior, please consult with a certified elder law attorney before submitting an application.