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What's Covered (Facilities and Services and the Reimbursements They Accept) Skilled Nursing Facilities (SNFs) Medicare What's Covered:
Conditions and Limitations There are strict limitations to Medicare coverage in skilled nursing facilities.
Medigap What It Covers Eight of the ten basic Medigap policies (Medigap Plans A-J) completely cover days 21-100 skilled nursing coinsurance; Medigap Plans K-L cover a portion. Managed Care What It Covers Managed Care policies cover everything that Medicare covers. Sometimes there is a co-payment, however, for days 21-100, that is usually about half the cost. In addition, no prior hospital stay is required. Conditions and Limitations
Medi-Cal Note: Medi-Cal recipients must give a portion of any social security income towards payment of skilled nursing facility services. What It Covers
Long-term Care Insurance (LTCI) What It Covers Facility Only and Comprehensive policies pay benefits in a skilled nursing facility, but the amount of coverage depends on the individual policy. Veterans Benefits What It Covers The Department of Veterans Affairs (VA) provides skilled nursing care to eligible veterans through VA and Community Contract facilities. Veterans who do not meet the conditions and limitations outlined below may still be eligible for nursing care when space and resources are available. Conditions and Limitations
Find a Skilled Nursing Facility in San Francisco County Home Health CareMedicare What It Covers Medicare is the principal provider of home health care in the country. Medicare covers a substantial part of home health care. Medicare does not cover in-home care. Your doctor must prescribe the following services and equipment for coverage:
Conditions and Limitations
Medigap What It Covers Medigap policies D, G, I and J have a benefit that covers home health and in-home care. The coverage varies according to the policy you choose. The benefits may include assistance with activities of daily living such as bathing, grooming, medication monitoring, meal preparation, light housekeeping, laundry, errands, grocery shopping and transportation. Conditions and Limitations In order to be eligible for these benefits, the individual must currently be receiving Medicare-covered skilled home health care. Managed Care What It Covers Utilizing its own network of doctors, hospitals and services, Managed Care policies cover everything that Medicare covers in terms of home health care. You must get authorization from the insurance company before receiving services. Medi-Cal What It Covers Medi-Cal pays for most skilled nursing services at home, including medical equipment that a doctor deems necessary, as long as it is less expensive than living in a skilled nursing facility. In-home Supportive Services (IHSS) What It Covers Services provided are based on an individual's needs, which may include home health and in-home care services such as:
Conditions and Limitations There is a maximum of 283 hours per month for these services. Depending on an individual's needs assessment, the maximum allowable hours may be less. Veterans Benefits What It Covers Home health care is provided by the VA or through contract agencies to veterans with chronic conditions. The services include skilled nursing, physical and occupational therapies, and social services. Conditions and Limitations
Medicare, Managed Care, Medi-Cal and Veterans Benefits do not cover in-home care. Medigap policies D, G, I and J cover in-home care if the individual is simultaneously receiving skilled home health care. As such, most in-home care is either paid for privately or by using a long-term care insurance (LTCI) policy. As many people wish to live at home as long as possible, LTCI policies have grown in popularity. Medigap What It Covers Medigap policies D, G, I and J policies have a benefit that covers home health and in-home care. The coverage varies according to the policy you choose. The benefits may include assistance with activities of daily living such as bathing, grooming, medication monitoring, meal preparation, light housekeeping, laundry, errands, grocery shopping and transportation. Conditions and Limitations In order to be eligible for these benefits, the individual must currently be receiving Medicare-covered skilled home health care. Long-term Care Insurance (LTCI) What It Covers LTCI policies vary. Some do pay in-home care benefits, but the amount of coverage depends on the individual policy. Conditions and Limitations Policies differ on conditions required to qualify for in-home care benefits. Each policy has a cap on the number of visits. Older policies require a prior hospital stay or time in a skilled nursing facility; the newer policies require that beneficiaries be physically or cognitively impaired. On Lok SeniorHealth What It Covers
Conditions and Limitations
In-home Supportive Services (IHSS) What It Covers Services provided are based on an individual's needs, which may include home health and in-home care services such as:
Conditions and Limitations There is a maximum of 283 hours per month for these services. Depending on an individual's needs assessment, the maximum allowable hours may be less. Find an In-home Care Provider in San Francisco County Medicare, Medigap, Managed Care and Medi-Cal do not cover care in assisted living facilities. Long-term care insurance policies (LTCI) and Veterans Benefits sometimes cover the cost of assisted living facilities. Most assisted living is private pay. Long-Term Care Insurance (LTCI) What It Covers Facility Only and Comprehensive policies pay benefits in an assisted living facility, but the amount of coverage depends on the individual policy. Veterans Benefits What It Covers Veterans Benefits refers to care in an assisted living facility as Community Residential Care. The program provides health care supervision to eligible veterans who are unable to live independently and do not have anyone to provide the required supervision and care. The veteran must be able to function with minimal assistance. Conditions and Limitations
On Lok SeniorHealth What It Covers Assisted living is not part of the package of services provided by On Lok SeniorHealth; however, On Lok manages and offers affordable senior housing at three locations in San Francisco. There is a waiting list for all On Lok housing. Conditions and Limitations
Find an Assisted Living Facility in San Francisco County Adult day care services are usually private pay. However, some day care centers offer need-based scholarships, and others have a sliding scale. Medicare, Medigap, Managed Care, Medi-Cal and Veterans Benefits do not cover adult day care. Long-Term Care Insurance (LTCI) What It Covers Homecare Only and Comprehensive policies pay benefits in an adult day care facility, but the amount of coverage depends on the individual policy. Find an Adult Day Care Center in San Francisco County Adult day health centers provide many health and social services for a set daily fee and many centers have sliding scales. Adult day health care programs start at about $96 per day. Medicare, Medigap and Managed Care do not cover adult day health care. Medi-Cal What It Covers Medi-Cal usually covers all adult day health services. Conditions and Limitations In some instances, Medi-Cal approves coverage for fewer days per week than an individual requires. If, for example, Medi-Cal approves only three days per week, but the individual requires five days, then the individual is financially responsible for the two additional days of attendance. Medi-Cal approves the number of days based on a doctor's recommendation. Long-term Care Insurance (LTCI) What It Covers Homecare Only and Comprehensive policies pay benefits in an adult day health care facility, but the amount of coverage depends on the individual policy. Veterans Benefits What It Covers Veterans Benefits cover adult day health care services. Conditions and Limitations
On Lok SeniorHealth What It Covers On Lok SeniorHealth operates seven adult day health care centers throughout the city of San Francisco, two of which (the centers at 1426 Fillmore Street and 2700 Geary Boulevard) are run in collaboration with the Institute on Aging. Each center maintains a full-service clinic and offers rehabilitation services. Noon meals and social day programs (including those specifically for dementia clients) are offered. Conditions and Limitations
Find an Adult Day Health Care Center in San Francisco County Geriatric care management is strictly private pay. Medicare, Medigap, Managed Care, Medi-Cal and Long-term Care Insurance (LTCI) do not cover the service. On Lok SeniorHealth What It Covers Case managers are available as part of the interdisciplinary team serving each enrolled individual. Conditions and Limitations
Veterans Benefits What It Covers While Veterans Benefits do not cover geriatric care management, they do cover Geriatric Evaluation and Management (GEM), a similar service that includes a comprehensive assessment of the veteran's physical, medical and emotional needs. The objective of the assessment is to build a customized plan of care that may include a combination of treatment, rehabilitation and social services. Conditions and Limitations The veteran must meet the eligibility criteria for VA benefits. Find a Geriatric Care Manager in San Francisco County Medicare is the principle provider of hospice care in the US, but Medicare Part A only pays for hospice care provided by a Medicare-certified program. About 90% of hospice organizations in the US are certified by Medicare. Managed Care policies cover everything that Medicare covers, but do have conditions and limitations. Medigap does not cover hospice care. Medi-Cal, Veterans Benefits, and certain long-term care insurance policies (LTCI) pay for hospice care. Medicare What It Covers There is usually a 210-day cap on Medicare-covered hospice care. The 210 days are split into two ninety-day periods, followed by a thirty-day period. Each period may be extended when a doctor re-certifies that the patient's condition remains terminal. In some circumstances, coverage may be extended indefinitely. Medicare pays for most hospice services, including:
Conditions and Limitations Patient's doctor and hospice medical director must verify that the patient has a terminal illness and probably has less than six months to live. Patient must sign a statement choosing hospice care instead of standard Medicare-covered benefits (Medicare will continue to cover health problems unrelated to terminal illness.) Important Note: Hospice agencies sometimes charge more than Medicare pays. In these instances, the patient is responsible for the balance. Before providing care, the hospice must advise the patient how much of the bill Medicare will pay and inform the patient, in writing, of any items or services not covered. The bill is sent directly to Medicare. The patient may be charged for:
Managed Care What It Covers Managed Care policies cover everything that Medicare covers. Conditions and Limitations Most policies only cover hospice care and services provided by Medicare-certified hospice agencies that are designated by the individual insurance company. Medi-Cal What It Covers
Conditions and Limitations Before Medi-Cal will approve coverage for hospice care, you must:
Note: Medi-Cal only pays for hospice care provided by a Medicare-certified agency. On Lok SeniorHealth What It Covers When needed, hospice is arranged through the On Lok physician assigned to the individual requiring hospice services. Conditions and Limitations
Long-Term Care Insurance (LTCI) What It Covers Homecare Only and Comprehensive policies usually cover costs of hospice care, while Facility Only policies generally do not. Conditions and Limitations Policies vary. Because of potential limitations on hospice care coverage, it is important to carefully compare policies when selecting long-term care insurance. Veterans Benefits What It Covers Veterans Benefits cover hospice care. Conditions and Limitations
Find a Hospice provider in San Francisco County Information provided by the Gilbert Guide. |
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