Health Column: Questions about Medicare

05/03/2011 8:54 AM |

Dear Marci,

Due to a recent stroke, I now have trouble with my speech. I would like to see a speech pathologist. Will Medicare cover this?
Toussaint

Dear Toussaint,

Yes. Medicare will help pay for speech pathology services if they’re  medically necessary and can only be provided by a qualified speech pathologist; your doctor or therapist sets up the plan of treatment; and your doctor periodically reviews the plan to see how long you will get therapy.

Generally, Medicare will cover therapy only if your condition can improve, or if your condition will deteriorate without therapy.
You can get these services as an outpatient of a participating hospital or skilled nursing facility, but you must qualify for the skilled nursing facility benefit. You can also get services from a participating home health agency, but you must qualify for the home health benefit; from a rehabilitation agency; a  comprehensive outpatient rehabilitation facility; or a public health agency. Medicare may also pay for services given by privately practicing speech pathologists.

In 2011, Medicare will cover up to $1,870 for physical and speech therapy combined. If you are approaching the limit and need more therapy, your doctor can tell Medicare that it’s medically necessary for you to continue. Medicare is most likely to cover additional therapy if your case is medically complicated.

Dear Marci,

I am about to be discharged from the hospital and my doctor thinks I should enter a skilled nursing facility. Can a skilled nursing facility decide not to accept me as a patient?

Nigel

Dear Nigel,

Yes. A Medicare-certified skilled nursing facility is not required to take you as a patient simply because your doctor has prescribed care for you and you qualify for such care under Original Medicare. Facilities are allowed to select which patients they accept, as long as they do not violate discrimination laws. A skilled nursing facility can also limit the kinds of services it provides and the types of conditions for which it will render care. If you need services that the facility doesn’t provide, the facility administrator may decide not to accept you as a patient.

A skilled nursing facility may decide, for example, that it won’t treat patients with dementia. Sometimes the facility won’t take you as a patient because it believes you don’t meet Medicare’s criteria for coverage, or because it has no staff available to take on new patients.

If you’re in a Medicare private health plan (like an HMO), your plan will generally pay for you to get care only from skilled nursing facilities that are within the plan’s network. You may be able to get care from a non-network facility and pay your plan’s rates if you were staying in the facility before a hospitalization; if the facility is a part of your continuing care retirement community; or if your spouse lives in the facility at the time of your hospital discharge.

Dear Marci,

My neighbor recommended I look into Medicare Savings Programs. What do these programs do?

Glenda

Dear Glenda,

Medicare Savings Programs, also known as Medicare Buy-In programs or Medicare Premium Payment Programs, help pay your Medicare costs if you have limited finances. There are three main programs, and each has different income eligibility limits.

• Qualified Medicare Beneficiary plans pay for Medicare Part A and B premiums, deductibles and coinsurances or co-pays. If you have such a plan, you should have no Medicare coinsurance or co-payment for Medicare-covered services you get from doctors who participate in Medicare, or who are in your Medicare private health plan’s network.

• Specified Low-income Medicare Beneficiary pays for the Medicare Part B premium.

• Qualifying Individual Program pays for the Medicare Part B premium.

To qualify for an MSP, you must have Medicare Part A and meet income and assets guidelines. If you do not have Part A but meet QMB eligibility guidelines, your state will have a process to allow you to enroll in Part A and QMB. Many states allow this throughout the year, but others limit when you can enroll in Part A.

States use different rules to count your income, but generally include income from wages or Social Security and assets, although some assets may not be counted.

Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare.