HIPAA

Your Health Information Is Protected By Federal Law

Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.

WHAT INFORMATION IS PROTECTED?

  • Information your doctors, nurses, and other healthcare providers put in your medical record
  • Conversations your doctor has about your care or treatment with nurses and others
  • Information about you in your health insurer’s computer system
  • Billing information about you at your clinic
  • Most other health information about you held by those who must follow these laws

WHO CAN LOOK AT AND RECEIVE YOUR HEALTH INFORMATION?

The Privacy Rule sets rules and limits on who can look at and receive your health information.

To make sure that your health information is protected in a way that does not interfere with your healthcare, your information can be used and shared:

  • For your treatment and care coordination
  • To pay doctors and hospitals for your healthcare and to help run their businesses
  • With your family, relatives, friends, or others you identify who are involved with your healthcare or your
  • health care bills, unless you object
  • To make sure doctors give good care and nursing homes are clean and safe
  • To protect the public’s health, such as by reporting when the flu is in your area
  • To make required reports to the police, such as reporting gunshot wounds

Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot:

  • Give your information to your employer
  • Use or share your information for marketing or advertising purposes or sell your information

For more information visit HIPAA

Medicaid

Long-Term Services And Support

The Medicaid program allows for the coverage of Long-Term Care Services through several vehicles and over a continuum of settings. This includes Institutional Care and Home and Community Based Long-Term Services and Supports. Information on these topics is below. For more information on additional community based topics, see the link to the right.

INSTITUTIONAL LONG-TERM CARE

Medicaid covers certain inpatient, comprehensive services as institutional benefits. The word “institutional” has several meanings in common use, but a particular meaning in federal Medicaid requirements. In Medicaid coverage, institutional services refers to specific benefits authorized in the Social Security Act. These are hospital services, Intermediate Care Facilities for People with Mental Retardation (ICF/MR), Nursing Facility (NF), Pre-admission Screening & Resident Review (PASRR), Inpatient Psychiatric Services for Individuals Under Age 21, and Services for individuals age 65 or older in an institution for mental diseases.

INSTITUTIONAL BENEFITS SHARE THE FOLLOWING CHARACTERISTICS:

Institutions are residential facilities, and assume total care of the individuals who are admitted.

The comprehensive care includes room and board. Other Medicaid services are specifically prohibited from including room and board.

The comprehensive service is billed and reimbursed as a single bundled payment. (Note that states vary in what is included in the institutional rate, versus what is billed as a separately covered service, for example physical therapy may be reimbursed as part of the bundle or as a separate service.)

Institutions must be licensed and certified by the state, according to federal standards.

Institutions are subject to survey at regular intervals to maintain their certification and license to operate.

Eligibility for Medicaid may be figured differently for residents of an institution, and therefore access to Medicaid services for some individuals may be tied to need for institutional level of care.

For more information visit Medicaid

Medicare

Skilled Nursing Facility (SNF) Care

HOW OFTEN IS IT COVERED?

Medicare Part A (Hospital Insurance) covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions for a limited time.

Medicare-covered services include, but aren’t limited to:

  • Semi-private room (a room you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy*
  • Speech-language pathology services*
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed
  • services that aren’t available at the SNF
  • Dietary counseling

*Medicare covers these services if they’re needed to meet your health goal.

WHO’S ELIGIBLE?

People with Medicare are covered if they meet all of these conditions:

  • You have Part A and have days left in your benefit period
  • You have a qualifying hospital stay
  • Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you’re in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.
  • You get these skilled services in a SNF that’s certified by Medicare
  • You need these skilled services for a medical condition that was either:
    • A hospital-related medical condition
    • A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition
  • Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.
  • Note: If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (for instance if you get the flu), you may be able to continue to get Medicare coverage temporarily.

YOUR COSTS IN ORIGINAL MEDICARE

  • You pay:
    • Days 1–20: $0 for each benefit period.
    • Days 21–100: coinsurance per day of each benefit period.
    • Days 101 and beyond: all costs.
  • Note: If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

Note: Your doctor or other healthcare provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

For more information visit Medicare

Resource Center

  • HIPAA
    • Your Health Information Is Protected By Federal Law

      Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.

      WHAT INFORMATION IS PROTECTED?

      • Information your doctors, nurses, and other healthcare providers put in your medical record
      • Conversations your doctor has about your care or treatment with nurses and others
      • Information about you in your health insurer’s computer system
      • Billing information about you at your clinic
      • Most other health information about you held by those who must follow these laws

      WHO CAN LOOK AT AND RECEIVE YOUR HEALTH INFORMATION?

      The Privacy Rule sets rules and limits on who can look at and receive your health information.

      To make sure that your health information is protected in a way that does not interfere with your healthcare, your information can be used and shared:

      • For your treatment and care coordination
      • To pay doctors and hospitals for your healthcare and to help run their businesses
      • With your family, relatives, friends, or others you identify who are involved with your healthcare or your
      • health care bills, unless you object
      • To make sure doctors give good care and nursing homes are clean and safe
      • To protect the public’s health, such as by reporting when the flu is in your area
      • To make required reports to the police, such as reporting gunshot wounds

      Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot:

      • Give your information to your employer
      • Use or share your information for marketing or advertising purposes or sell your information

      For more information visit HIPAA

  • Medicaid
    • Long-Term Services And Support

      The Medicaid program allows for the coverage of Long-Term Care Services through several vehicles and over a continuum of settings. This includes Institutional Care and Home and Community Based Long-Term Services and Supports. Information on these topics is below. For more information on additional community based topics, see the link to the right.

      INSTITUTIONAL LONG-TERM CARE

      Medicaid covers certain inpatient, comprehensive services as institutional benefits. The word “institutional” has several meanings in common use, but a particular meaning in federal Medicaid requirements. In Medicaid coverage, institutional services refers to specific benefits authorized in the Social Security Act. These are hospital services, Intermediate Care Facilities for People with Mental Retardation (ICF/MR), Nursing Facility (NF), Pre-admission Screening & Resident Review (PASRR), Inpatient Psychiatric Services for Individuals Under Age 21, and Services for individuals age 65 or older in an institution for mental diseases.

      INSTITUTIONAL BENEFITS SHARE THE FOLLOWING CHARACTERISTICS:

      Institutions are residential facilities, and assume total care of the individuals who are admitted.

      The comprehensive care includes room and board. Other Medicaid services are specifically prohibited from including room and board.

      The comprehensive service is billed and reimbursed as a single bundled payment. (Note that states vary in what is included in the institutional rate, versus what is billed as a separately covered service, for example physical therapy may be reimbursed as part of the bundle or as a separate service.)

      Institutions must be licensed and certified by the state, according to federal standards.

      Institutions are subject to survey at regular intervals to maintain their certification and license to operate.

      Eligibility for Medicaid may be figured differently for residents of an institution, and therefore access to Medicaid services for some individuals may be tied to need for institutional level of care.

      For more information visit Medicaid

  • Medicare
    • Skilled Nursing Facility (SNF) Care

      HOW OFTEN IS IT COVERED?

      Medicare Part A (Hospital Insurance) covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions for a limited time.

      Medicare-covered services include, but aren’t limited to:

      • Semi-private room (a room you share with other patients)
      • Meals
      • Skilled nursing care
      • Physical and occupational therapy*
      • Speech-language pathology services*
      • Medical social services
      • Medications
      • Medical supplies and equipment used in the facility
      • Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed
      • services that aren’t available at the SNF
      • Dietary counseling

      *Medicare covers these services if they’re needed to meet your health goal.

      WHO’S ELIGIBLE?

      People with Medicare are covered if they meet all of these conditions:

      • You have Part A and have days left in your benefit period
      • You have a qualifying hospital stay
      • Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you’re in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.
      • You get these skilled services in a SNF that’s certified by Medicare
      • You need these skilled services for a medical condition that was either:
        • A hospital-related medical condition
        • A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition
      • Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.
      • Note: If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (for instance if you get the flu), you may be able to continue to get Medicare coverage temporarily.

      YOUR COSTS IN ORIGINAL MEDICARE

      • You pay:
        • Days 1–20: $0 for each benefit period.
        • Days 21–100: coinsurance per day of each benefit period.
        • Days 101 and beyond: all costs.
      • Note: If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

      If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

      If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

      Note: Your doctor or other healthcare provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

      For more information visit Medicare