Tricare Nursing Home Coverage

Posted: September 21, 2011 in Uncategorized

At some point in your life, you or a family member may need skilled nursing care, long-term care or both. You should understand what each term means and how they affect you. Under TRICARE, a skilled nursing facility is a facility with the staff and equipment to provide skilled nursing, skilled rehabilitation or other medically necessary healthcare services, including prescription medications. Skilled nursing care isn‘t typically provided in a nursing home or a patient's home. For TRICARE to cover your skilled nursing facility admission you must meet the following criteria:
 You must be treated in a hospital for at least three consecutive days, not including the day of discharge;
 You must be admitted within 30 days of your hospital discharge (with some exceptions) to a skilled nursing facility;
 Your doctor‘s treatment plan must demonstrate your need for medically-necessary rehabilitation and skilled services; and
 The facility must be Medicare-certified and a participating provider.
Under skilled nursing care, TRICARE typically covers Medically-necessary skilled nursing care; Rehabilitative (physical, occupational, and speech) therapies; Room and board; Prescribed drugs and laboratory work; Supplies; Appliances; and Medical-equipment. The amount you pay varies, depending on your eligibility status and TRICARE option. Your costs are different depending on who you are and which health plan option you are using. To determine your cost refer to the chart at Medicare and TRICARE have the same benefits, skilled nursing facility decision process and payment calculation method, except TRICARE doesn‘t limit the benefit to 100 days (after obtaining a Medicare claim denial). If you are Medicare and TRICARE eligible:
 For days 1 to 20, Medicare pays 100 percent;
 For days 21 to 100, Medicare covers all costs, except for the required Medicare copayment. TRICARE covers the copayment; and
 After day 100, TRICARE is the primary payer and you pay TRICARE beneficiary cost shares.
TRICARE covers medically necessary equipment costing more than $100, such as wheelchairs, hospital beds, and respirators. You may buy or rent the equipment (whichever costs less). Send your doctor's prescription with your claim, specifying the type of equipment, why you need it and for how long. TRICARE won‘t cover general use equipment, such as air cleaners or whirlpool baths. Before getting durable medical equipment, check with your region‘s toll-free call center about rules and coverage limitations. TRICARE and Medicare will not pay for Long-term care. This includes support services for patients with a degenerative condition (Parkinson‘s, stroke, etc.), a prolonged illness (cancer) or cognitive disorder (Alzheimer‘s). A trained professional doesn‘t have to provide long term care and it may be given in nursing homes, assisted living facilities, adult day care centers or in your home. Long-term care services include help with the following: Walking; Personal hygiene; Sleeping; Using the bathroom; Dressing; Cooking/feeding; Medication; and Moving from a bed to a chair. All such care is your financial responsibility. So ask the facility whether you are getting skilled nursing care or long-term care. Ask your regional contractor or case manager about exceptions or partial exceptions to the "no coverage" guidance. For skilled nursing care and long-term care issues contact your TRICARE Service Center or your regional contractor.
Hospice care is available for terminally ill patients expected to live six months or less if the illness run sits normal course. A Medicare-approved program must provide the hospice care, which may include: Physician services; Nursing care; Counseling; Inpatient respite care; Medical supplies; Medications; Home health aide services; and Short-term acute patient care. TRICARE Standard pays the full cost of covered hospice care services, except for small cost-share amounts the hospice may collect for drugs and inpatient respite care. Check with your regional contractor for details. For more information, visit the TRICARE website [Source: | Benefits article 1 Aug 2011 ++]


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