Elder Maze: Medicare path filled with many twists, turns

‘Welcome to Medicare” was the code name for my early May physical. While my Medicare birthday was just three days ago, I was eligible to use Medicare benefits on May 1. So I had the introductory physical. And today, I had the second of two cataract surgeries under that Medicare benefit.

So today seems a good day to begin exploring the complex health program for elders called Medicare. Frankly, it’s tempting to join with the countless others who poke fun at Medicare, like freelance writer Sheila Moss:

“I believe I have found the explanation for forgetfulness in our aging population: Medicare. Like most people, I didn’t give a flip about understanding Medicare and thought old people were just being senile by not understanding it. After all, it’s just insurance. How difficult can it be? Now I’m suffering from Medicare-induced dementia myself.”

I’ll resist throwing out one-liner Medicare zingers today. Instead, I’d like to offer a few basic observations that may be helpful to those who will soon be eligible for Medicare. Those already into the Medicare path of the Elder Maze have both horror stories and salvation stories. It’s not an even path.

At its basic best, Medicare is a federal health insurance program for persons 65 years or older, some disabled persons under 65 years old, and persons with end-stage renal (kidney) disease. Persons nearing 65 are automatically enrolled in Medicare A (hospital benefits) in their birth month.

Various Medicare programs are covered like a mini-alphabet soup: Part A, Part B, Part C and Part D. Everyone gets Part A at no extra cost (except deductibles). It covers hospital stays, skilled nursing facility care, home health care and hospice care.

Part B covers non-facility medical costs: doctors’ services, therapies, outpatient care, etc. Part C is a combination of A and B and is administered through private insurance companies’ “Medicare Advantage Plans.” Part D is the new, and still evolving, prescription drug plan.

It is very helpful to have some kind of additional insurance to pay for what Medicare doesn’t cover. The good news is many have that supplemental insurance. The bad news is that some are not able to afford it.

There are many twists and turns on the Medicare path in The Elder Maze. Some you may be able to avoid altogether. Others will be easier to navigate simply if you know they are there so you won’t be surprised.

For instance, if a person with Medicare is in the hospital and then needs to go to a skilled nursing facility for rehabilitation or long-term care, it is tempting to assume that Medicare will pay for the whole time. But there are unbending limits attached to Medicare’s coverage.

First a person must be in the hospital at least “three midnights.” It’s easier to think in this way than “three days” when calculating your time in the hospital. Too often, I’ve seen a person come to a nursing home after only two midnights in the hospital. Alas, no Medicare coverage for him.

Also, in the skilled nursing facility, Medicare pays fully for only the first 20 days. Then Medicare shares the cost with a person’s supplemental insurance – as long as skilled nursing or rehabilitation services are required – for up to 100 days.

Beyond those 100 days, Medicare doesn’t pay anything unless something else lands the person back in the hospital for another “three midnights” stay.

I will explore other Medicare matters in future columns. If you use the Internet, please check out the following sites for further information: www.medicare.gov; www.insurance.wa.gov/consumers/Shiba (for Washington), and www.doi.idaho.gov/shiba/shibahealth.aspx (for Idaho).