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The approved amount is an important concept for people with Medicare to understand. In this article, we’ll define the term “approved amount” and explain how it relates to nursing home abuse.

Key Takeaways

  • A Medicare-approved amount is an amount that Medicare pays for an individual’s medical services
  • Medicare only pays out for medical services after the patient's deductible has been met
  • Exact deductible costs and approved amounts for specific services vary by Medicare plan
  • Medicare pays part of the cost of a short-term stay at a nursing home, but does not pay for long-term stays

What Is an Approved Amount?

An approved amount, also called a Medicare-approved amount, is the amount that the U.S. national health insurance program Medicare pays a provider for an insured individual’s medical services. 

Approved amounts apply to two types of healthcare providers: participating providers and nonparticipating providers. 

Participating providers are contracted to accept the amount Medicare has set for healthcare services. As such, they agree to take the approved amount as full payment for their services. Nonparticipating providers accept some but not all Medicare service assignments, and may charge the patient the difference between the approved amount and their normal service charges, up to an additional 15% of the Medicare-approved amount. 

Like with private health insurance, Medicare only pays out for medical services after the patient has met their deductible. The exact deductible cost varies according to the Medicare plan. 

Medicare-approved services also vary by plan type as follows:

  • Medicare Part A covers hospital services
  • Medicare Part B covers outpatient medical services
  • Medicare Advantage covers services provided by Medicare parts A and B and adds prescription drugs, dental, vision, and hearing
  • Medicare Part D covers prescription drugs

Some of the most common Medicare-approved services include:

  • Physical therapy
  • Chemotherapy
  • Cardiovascular screenings
  • Mammograms
  • Durable medical equipment
  • Bariatric surgery

To learn the approved amount for a specific service, it is recommended to speak directly to your provider.

Approved Amount and Nursing Home Abuse

Nursing homes, facilities for the residential care of older and disabled people, can be quite expensive. It’s natural to wonder if Medicare may be able to help pay some of this cost.

Currently, Medicare Part A pays only for short-term stays at nursing homes if the patient was formally admitted to the hospital for at least three consecutive days beforehand for the same illness or a condition related to it. A doctor must also certify that the patient needs daily skilled care at a nursing home. The benefit period begins the day an individual is admitted to the hospital as an inpatient or the day they become a patient in a nursing home.

Medicare will cover the following nursing home costs:

  • Medications, medical equipment, and supplies used in the facility
  • Ambulance transportation
  • A semi-private room and meals
  • Occupational therapy, physical therapy, or speech and language pathology services
  • Medical social services
  • Dietary counseling
  • Skilled nursing care

The approved amounts for a short-term nursing home stay are as follows:

  • $0 for days 1 to 20
  • $194.50 a day for days 21 to 100
  • All costs days for 101 and beyond

Note that Medicare does not pay the costs of a long-term stay at a nursing home. However, Medicaid, a social healthcare program for people with low incomes, does. 

All residents of nursing homes and their loved ones are cautioned to be knowledgeable about and aware of the risk of nursing home abuse. If you or somebody you care about has experienced nursing home abuse, it is recommended that you speak to the relevant authorities immediately. An attorney may also be able to help you determine whether or not you have grounds for a lawsuit to recover compensation for your losses and injuries.

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