Developmentally Disabled
Check Medicare Eligibility
For some residents with developmental disabilities, Medicare fully covers medical care costs during the first 20 days following a hospital stay, then provides only partial payment, up to a maximum of 100 days. Coverage is restricted to skilled nursing or rehabilitation services only. Also, the facility must be certified by Medicare and agency officials must approve the need for the care before Medicare will pay anything.
Medicare does not pay for the cost of most care in a care facility, with the exception of limited therapy or nursing visits that qualify as home health care or hospice care at the end of life.
Who Is Eligible
Medicare is a federal health insurance program for people age 65 and older, adults who receive Social Security payments, some disabled people under 65, and those with end-stage renal disease.
To find out more about eligibility, use the Medicare Eligibility and Enrollment Date Calculator.
What Is Covered
There are two parts to Medicare that may help pay for a very limited amount of the care required by those who have developmental disabilities:
Part A pays for most inpatient hospital care, some inpatient skilled nursing home care, some home health care, and hospice care.
Part B pays for doctors’ services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies. Those who don’t automatically qualify for Medicare because they receive Social Security payments may get coverage by paying a premium.
Medicare covers care received in a Medicare-certified facility for only a short time — up to 100 days. While this is not a long term solution, it may give patients and families a little breathing room to find and finance a facility if extended care is needed.
Coverage includes daily skilled nursing or rehabilitation services provided by a registered nurse, or physical, speech, or occupational therapist following a hospital stay.
Coverage is limited to 100 days per illness. The first 20 days are covered in full; the additional 80 days require a copayment. The 100 days are not guaranteed, and Medicare must approve the length of stay in the facility. If Medicare decides that daily skilled nursing or rehabilitation is no longer needed, payments stop. Residents must then seek Medi-Cal coverage.
How to Apply
Those who already receive Social Security benefits are automatically enrolled in Medicare Part A and Part B the month they turn 65.
Those who wish to get both Social Security benefits and Medicare can apply online.
Those who wish to apply for Medicare alone must call the Social Security Administration at 800-772-1213 or 800-325-0778 (TTY) or contact the local Social Security office.
Other Medicare-Approved Plans
A number of plans approved by Medicare but run by private companies offer health and prescription drug coverage. For example, Medicare Advantage plans provide Part A and B benefits, but charge different amounts for certain services — and may offer more coverage for an extra cost. Medicare Advantage Plans are HMOs, PPOs, or private fee-for-service plans. If you are enrolled in a Medicare Advantage plan, Medicare services are covered through the plans and are not paid for under Original Medicare.
Other plans, including Medicare Cost Plans and Demonstration or Pilot Programs, provide Part A and B coverage; some also cover prescription drugs. While these plans are offered to increase the number of coverage options available to consumers, there are still confusing kinks in timing, coverage, and cost. For answers to specific questions, contact the main Medicare office at 800-633-4227 or 877-486-2048 (TTY).
For information on Medicare coverage, visit the Medicare Web site.
For more information on Medicare coverage and its costs, including free individual counseling, contact the local office of the Health Insurance Counseling and Advocacy Program (HICAP).
For advocacy and education about Medicare, contact California Health Advocates.
Medigap Coverage
Medigap insurance, or Medicare supplemental insurance, is designed to cover the gaps in what Medicare pays. While the policies do not specifically cover care in a facility, they are often an important part of an insured’s complete plan.
In California, 12 standard Medigap plans are sold by private insurance companies, regulated by state and federal law, and must be clearly labeled as Medicare supplements and identified by the letters A through J.
Plan A, the basic benefit package, covers:
- Medicare Part A co-insurance, plus coverage for 365 additional days of hospitalization after Medicare benefits end;
- Medicare Part B co-insurance (the 20% of medical services that Medicare does not pay);
- The first three pints of blood each year, which Medicare does not pay for; and
- Medicare Preventive Care Part B co-insurance.
The other packages contain various combinations of additional benefits, which may include:
- Hospice care co-insurance or copayment;
- Skilled nursing facility care co-insurance;
- Medicare Part A deductible;
- Medicare Part B deductible;
- Medicare Part B excess charges;
- Foreign travel emergency coverage;
- At-home recovery coverage; and
- A limited amount of preventive care not covered by Medicare.
For more information and guidance on buying Medigap policies and an explanation of rights under them, see "Choosing a Medigap Policy — A Guide to Health Insurance for People with Medicare," also available in Spanish and large print editions.
Dual Coverage with Medi-Cal
Some people who qualify for Medicare benefits and have low income and asset levels may also qualify for full Medi-Cal coverage. For such people, known as “dual eligibles” or “Medi-Medis,” Medicare will pay for the benefits it covers, and then Medi-Cal will provide secondary coverage. Also, for those with such dual eligibility, Medi-Cal may cover deductibles and copayments for Medicare Part A, and premiums for Part B.
