< Back to article

Who is Eligible for Medicare?


I get the best of care with Medicaid based on my specific need I get the best of care with Medicaid based on my specific needs all my needs are met for the most part but I want to move to Florid I get the best of care with Medicaid based on my specific needs all my needs are met for the most part but I want to move to Florida how can I navigate that wit I get the best of care with Medicaid based on my specific needs all my needs are met for the most part but I want to move to Florida how can I navigate that without losing so much in the process.

from CMS - "The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program."
There are about 100 of them set up so far & they seem to be done with a partnership of some regional COG's Area Council on Aging. I'd bet that if your state is not participating with state set up on the ACA / Obamacare, you aren't getting CCTP's.

What is "community based care"?

osmi - An "on-call" home health care is almost always private pay. Now they can get community based care & services as a part of Medicaid if they qualify for Medicaid and their MD prescribes a specific service covered by Medicaid.

MediCARE is primarily for hospitalization, rehab and for health care provider services (like doctors, PT & OT, lab work, scans, drugs, etc.). If your MD will write orders for a specific home health care service to be provided that is covered under Medicare's rules, then Medicare will pay for it for a specific period of time.
Like MD can write for at-home PT for 6 weeks as part of rehab from post surgery - but the patient has to be progressing in their rehab (in general) in order for Medicare to pay for the whole period of time. In general Medicare is for specific & short-term health care services provided by a licensed provider that can be coded for payment by CMS through the Medicare program. Most vendors will not take Medicare as full payment either as it pays only 80% so either you have to private pay the 20% or have a secondary Medicare plan - like what Decatur so well described. Medicare is not for long term care services.

I am interested in on call/prearranged home care for a dementia patient. What part of that care is covered by Medicare?

Railroad Retirement is a slightly different creature for Medicare. We've had RR in our family so this is based on our experience:
- first of all RRB (Railroad Retirement Board) pays really really well for retirees (as opposed to the paltry $ 500 - 800 a month that SS pays) which can pose it's own problems if family needs to go to Medicaid to pay for long term care at some point in time, so you do kinda need to keep that in the back of your mind for planning.
- second, if RR retirees are on Original Medicare, there is a different coding system for payments under RRB. If a vendor does their regular route to submit a charge under Medicare, it will get kicked back from CMS (Centers for Medicare & Medicaid aka the feds). Often this will take a few months to surface and the vendor will be unhappy as they have not gotten paid and family will face a bill they can't understand why it wasn't paid. For RRB, the bill has to be submitted to a specific Medicare contractor for RRB which is Palmetto in Georgia. Palmetto knows the coding for RRB/Medicare and do this for claims from all over. They know their stuff and are helpful.
- for those RRB families who are looking at NH placement for their elder…..if you are in an area where there is a railhead, then the local NH's may actually have some experience in dealing with RRB as they have had other RRB residents. But if not, the challenge is that RR pays really well and waaaaay beyond what is allowed under the state's Medicaid income limits. So the NH looks at their income, the NH will assume they are private pay. If this is the case, often a NH will take the resident with their RRB check as full pay. It's not unusual for the check to be 4K- 6K which is a huge "SOC" (or share of cost in Medicaid speak) as opposed to the $ 500 - 800 a month SOC from a SS check then the NH having to bill and get the rest from the state's Medicaid program plus do whatever the state wants for compliance & reporting. Some NH totally love having RRB residents because of this but works only if the NH understands just what RRB does & pays.


Typical confusion regarding Medicare:
Do not confuse the Alphabet labeled MEDICARE supplements with MEDICARE part A,B,C, or D.
A= Hospital
C= Availability of Medicare Advantage Plans (which ARE NOT Medicare Supplements)
D= Rx Drug Plans

You do not have to sign up for Medicare (to avoid penalties), if you have certified coverage under an employer or spouse employer plan., but need to when that coverage ceases!

Medicare Advantage plans may offer additional benefits, each plan differs; some are free, some have fees, and differing deductibles. Some advantage plans have combined part D Rx coverage; beware Medicare Advantage plans can change or drop yearly, so in a combined plan you lose your Rx plan as well.
For that reason one may consider a stand alone Rx plan when looking at combined plans.

Why Medicare Supplements:
They cover the other 20% of Medicare approved charges, and DO NOT require a network, They offer coverage choices, but all plans by all companies no matter which 'category' (Supplement letter name), must offer the same benefits).

Important: these plans are 'underwritten', they have health requirements; BUT they are guaranteed issue; when first eligible for Medicare!, and are not subject the yearly changes of Medicare Advantage!
Each plan has different rates, some cover foreign travel, I personally recommend the HIGH DECUCTIBLE PLAN 'F" sometimes called "HDF", because of it's extensive coverage and very low rates.
(It may not be available from all carriers or agents)