Wednesday, September 28, 2022

Does Medicare Pay For 100 Days In A Nursing Home

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Medicare Coverage For Nursing Home Care

Medicare Part A What does 100 Days of Skilled Nursing Care Mean?

It is not that Medicare does not pay for any nursing home care. It does pay for some, but only if you were recently admitted to the hospital and only if you require skilled care at least five days per week.

Not only do you need to have been hospitalized to qualify for this Medicare Part A coverage, but you need to have been admitted as an inpatient for at least three days. Trickily, the day you are transferred to the skilled nursing facility does not count, and even more tricky is how CMS defines inpatient care.

These days you can stay overnight in the hospital, but that does not mean you are an inpatient. Thanks to legislation put forth in October 2013, known as the Two-Midnight Rule, you may only be considered for inpatient care if your stay is expected to last longer than two midnights and if your level of care is considered medically necessary. That means you cannot be in the hospital receiving care that could just as easily be administered elsewhere.

Otherwise, you will be placed under observation, care that is covered by Medicare Part B.

In the case that you do get approval for skilled nursing care, Medicare Part A covers the first 20 days for you. For days 21 to 100, you will pay $194.50 per day as of 2022. After 100 days, you are on your own.

How To Find Nursing Homes That Accept Medicaid Near Me

Below are a few resources and tips for finding a Medicaid-approved nursing home in your area.

  • Use Medicaid’s search tool. This online tool lets you look for pre-vetted facilities by Zip Code.
  • Ask your doctors if they service any Medicaid-certified nursing homes.
  • Ask friends, family, and colleagues you trust.
  • Contact an Aging and Disability Resource Center .
  • If you’re in the hospital, talk to a social worker about post-discharge care planning.
  • They may be affiliated with or know reputable, certified Medicaid nursing homes.

Don’t Leave Your Hard-Earned Benefits Behind. Call to get connected with a licensed agent.

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How To Fund Nursing Home Care

Most people who live in a nursing home will need to pay for their care out of pocket from private resources.

The Medicaid program may help people with limited resources who need a nursing home. However, not all nursing homes accept Medicaid payments.

An individuals Social Security benefit will not help with nursing home costs.

However, some older adults may qualify for supplemental security income in addition to Social Security, which could help fund nursing home care. A person can find out if they are eligible for this needs-based program by researching the Social Security disability program.

Private insurance companies offer long-term care policies that can pay for skilled and non-skilled care. The terms of these policies may vary depending on the provider. Some may cover nursing home care. Others include coverage for a range of medical services.

An existing life insurance policy may also provide cover for long-term care.

Read Also: What Is Medicare Open Enrollment

Where Can I Get Help Planning For A Stay In Rehab

While youre in treatment, you can chat with a Medicare representative about coverage limitations. Your doctor, a representative from your supplementary insurance provider, and the care planner at your rehabilitation center may all be able to offer you with the information you want. You can also work with a qualified Medicare benefits consultant or a senior financial planner to make your coverage decisions. These specialists can provide you with up-to-date information and assist you in determining your Medicare coverage for rehabilitation services.

When Medicare Won’t Pay For Nursing Home Care

Does Medicare Cover Skilled Nursing?

Shereen Lehman, MS, is a healthcare journalist and fact checker. She has co-authored two books for the popular Dummies Series .

Medicare is not a one-stop-shop. While it covers a wide breadth of services, it may leave you to fend for yourself when it comes to certain healthcare essentials as you grow older. For example, it doesn’t cover corrective lenses , dentures, hearing aids, or white canes for the blind. Certain medications are off the table, too, even if you have a Part D prescription drug plan.

This is because Medicare does not consider these things to be medically necessary. Unfortunately, what they also do not see as medically necessary are custodial care and long-term nursing home placement.

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Advantages Of A Nursing Home

Even if you live with loved ones, they might not be able to provide the level of care you need. Whether you need medical help or custodial help , it can be demanding for loved ones to give this constant care and to do it right.

  • Nursing homes have trained staff most have skilled nurses and nursesâ aides available 24/7. Often a doctor is on the staff or makes frequent visits to the home.
  • Nursing homes have government oversight the Centers for Medicare & Medicaid Services contracts with every state to inspect all nursing homes that participate in Medicare or Medicaid.
  • Some nursing homes function like hospitals, with nursesâ stations on each floor, and they provide physical, speech, and occupational therapy, in addition to medical care.
  • Other nursing homes feel more like your own personal homeâresidents may have open kitchens and interact with neighbors, and the staff is encouraged to develop relationships with residents.
  • Many nursing homes have special care units for people with serious memory problems, such as Alzheimerâs disease.
  • Some homes will let couples live together.
  • Nursing homes are for anyone who requires 24-hour care and not just for the elderly.

A Note About Medicare Rehab Coverage During The Covid

There is so much space for interpretation surrounding the regulations for Medicare coverage that it is easy for families to become befuddled about how to pay for care in skilled nursing facilities. Overall, attention and advocacy are required to ensure that aging loved ones receive the competent care they require and the coverage to which they are entitled. Family caregivers must ensure that the hospital professionals and skilled nursing facility staff provide precise instructions and justifications for the specialized services that are required to enhance the health and safety of their loved ones.

A geriatric care manager to keep track of your loved ones nursing home paperwork and timeline, as well as accompany you to care plan meetings, may prove to be a sensible decision.

Even if your loved ones Medicare coverage has expired during their benefit term, a GCM may assist you in locating and obtaining other forms of financial support as well as alternate types of care.

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Does Medicaid Cover Nursing Homes

Medicaid covers nursing home costs if you qualify. Medicaid is the largest fund-source for nursing home care. For eligible seniors, Medicaid covers long-term nursing home care in Medicaid-certified facilities4 when medically necessary. You’ll have to be under a certain income level and meet other state-specific requirements to qualify.5

All 50 states offer Medicaid, but nursing home services, cost coverage, and eligibility requirements vary widely by state. For example, each state sets its own income limit to determine if you are eligible for Medicaid. Not all nursing homes accept Medicaid, so check with each facility.

Unlike Medicare, Medicaid does not impose an official time limit on nursing home stays as long as they’re in a licensed and certified Medicaid nursing facility.

What Is Covered by Medicaid

  • Long-term care covers nursing home stays for qualifying patients needing ongoing care for a chronic mental or physical condition.
  • Skilled nursing and related medical care.
  • Rehabilitation from illness, injury, or disability.

Misconception : I Heard That Medicare Always Pays For Rehabilitation At A Nursing Home

How Medicare pays for your Nursing Home Care

For many, rehabilitation after an injury or illness serves as their first introduction to long-term care. Although these rehab stints are often short-term in nature, the admission process is similar to the application process for permanent placement in a nursing home. In both cases, disclosure of financial and insurance coverage information is needed to determine placement.

While federally-run Medicare does cover the costs of skilled nursing rehabilitation, there are limitations. To start, Medicare coverage kicks in only if the rehabilitation guest has been previously admitted to a hospital for a minimum of 3 days, with a safe discharge planned from that hospital to a licensed skilled facility. And while Medicare Part A does provide coverage for inpatient rehabilitation, coverage is capped at 100 days. Additionally, full coverage of all nursing homes costs only come during the first 20 days, with copayments applicable for days 21-100.

So while Medicare can cover quite a bit of the costs of a typical rehabilitation stay, it is important to know about coverage limitations in advance.

Also Check: How To Avoid Medicare Part D Penalty

What Does Medicare Pay For

Original Medicare includes Parts A and B. Medicare Part A covers inpatient services such as hospital and skilled nursing facility care. Your skilled nursing costs in 2020 include:

  • Days 1-20 cost $0 per benefit period
  • Days 21-100 have $194.50 Part A coinsurance per day, per benefit period
  • Days 101 and beyond you pay 100 percent of costs.

Your Part A coverage includes a semi-private room , meals, and skilled nursing care. If meeting your health goals requires it, you’ll also receive physical therapy, occupational therapy, and/or speech-language pathology services. You’ll find the full list of covered SNF services on Medicare.gov here.

Medicare Part B pays for medical services like doctor visits and durable medical equipment . However, if you’re being treated by a skilled nursing facility, any DME required for your condition should be provided by the SNF.

Inpatient Rehabilitation Facility Costs

The following are the costs associated with rehab at an inpatient rehabilitation facility:

  • After youve reached the Part A deductible, you normally dont have to pay anything for days 160 in a single benefit month. For days 6190 of a benefit period, you must pay a per-day premium established by Medicare. Medicare allows you to spend up to 60 lifetime reserve days at a per-day price established by Medicare for days 91150 of a benefit period
  • You are responsible for 100 percent of the cost of days 150 and beyond of a benefit period

Depending on your Medicare Advantage plan, your inpatient rehab coverage and expenses may be different. Additionally, depending on your Medicare supplement plan, part of your inpatient rehab expenditures may be covered. For further information, contact your plans provider. It is also possible that your charges will be different if you were moved to an inpatient rehab facility immediately from an acute care hospital or within 60 days of being discharged from an acute care hospital. For the care you get at the inpatient rehab facility, you will not be required to pay a deductible if you previously paid a deductible for the care you received during the previous hospitalization within the same benefit period.

Recommended Reading: Who Funds Medicare And Medicaid

How Long Will Medicare Cover A Nursing Home Stay

Medicare Part A may pay for medical services at a long-term care facility for up to 100 days. After this period, Medicare may still be used to cover some treatments, such as occupational therapy, speech therapy or speech-language pathology. However, Medicare wont cover room and board after 100 days.12

What Skilled Nursing Facility Costs Does Medicare Cover

How Long Does Medicare Pay for Skilled Nursing Care?

Medicare can cover many of the services you receive in a skilled nursing facility, such as:

  • A semiprivate room and meals
  • Skilled nursing care
  • Medical social services and dietary counseling
  • Medications, medical equipment and supplies used in the facility
  • Occupational therapy, physical therapy or speech and language pathology services if needed to meet your health goal
  • Ambulance transportation if needed to receive necessary services that arent available in the facility

Also Check: How Much Do I Have To Pay For Medicare

What If You Need More Time

Generally speaking, standard Medicare rehabilitation benefits expire after 90 days each benefit term. If you are able to return home but require rehab again within the following benefit period, the clock begins to tick again and your services are invoiced in the same manner as they were the first time you entered rehabilitation. Medicare may continue to assist with the expense of your rehab if your stay is continuous and lasts longer than the authorized 90 days. Medicare may do this by deducting from your lifetime reserve days.

In the event that you enroll in Medicare, you will be granted a maximum of 60 reserve days during your lifetime.

These days are basically a short extension of your Part A benefits that you can use if you need them but, they cannot be renewed and, once used, they are no longer available to you in the future.

With 3 Solutions For Protecting Yourself And Your Family

Are you unsure about the difference between Medicare and Medicaid? If so, you are certainly not alone. The two programs are commonly confused, which can lead to uncertainty, particularly when coordinating long-term care services.

Medicare and Medicaid are similar in that both are government programs offering health care coverage to those who qualify. This however is where the similarities end. Qualifying criteria and enrollment processes between the two programs are also very different. Medicare and Medicaid are even funded by different sources.

If you find yourself navigating the long-term care system for the first time on behalf of yourself or a family member or client, sorting through what Medicare and Medicaid does and does not cover could prove to be a challenge. Being aware of these misconceptions about Medicare, Medicaid, and what they do and do not cover can better prepare you to keep it all straight.

Recommended Reading: How To Find A Patient’s Medicare Number

Why Would I Need Skilled Nursing Care

When you are discharged from the hospital due to an injury or new illness, your doctor will determine if you need additional care. This decision is based on your ability to take care of yourself at home, if you have help available at home, and what kind of care is needed for your medical condition.

If you need special therapies or treatments to recover, or your condition requires a professional or trained help, the doctor may say you need skilled nursing care.

In 2019, the most common conditions that required skilled nursing care were:

How Much Of The Cost Will Medicare Cover For A Stay At A Skilled Nursing Facility

Medicare and your CalPERS Health Benefits

Original Medicare will cover a portion of the costs for up to 100 days for treatment during a benefit period at a skilled nursing facility. The first 20 days in residential care are fully covered by Medicare. Any stays during the remaining 80 days per benefit period, you will be responsible for $194.50 per day in coinsurance. Starting at day 101 and beyond, all cost will be payable by you while you are receiving care at a skilled nursing facility.

The cost of care at nursing homes and assisted living facilities

The average cost of a nursing home stay in 2021 was just over $108,000 per year, slightly more than double that of an assisted living facility, $54,000 annually, according to a Genworth Cost of Care Survey.

The daily rate varies widely from state to state with one in Missouri costing $195 compared to $1,036 in Alaska. The difference between assisted living residencies is more moderate, $3,000 in Missouri per month versus $6,978 in the District of Columbia.

Another aspect of the assisted living crisis for seniors is that many in debt themselves to access care. Progressive activist Dan Whitfield has called attention to the financial issues faced by seniors who require this care. Many, according to Whitfield, use their entire savings to live out the rest of their days until they eventually fire for bankruptcy and end up on Medicare.

Recommended Reading: How Do I Sign Up For Medicare A

Medicare Advantage Plans Also Cover Rehab

Medicare Advantage plans are required to provide the same benefits as Original Medicare. Many of these privately sold plans may also offer additional benefits not covered by Original Medicare, such as prescription drug coverage.

This means that a Medicare Advantage plan will pay for your qualified rehab in the same ways that Medicare Part A and Part B would. You could potentially find a Medicare Advantage plan that also offers other benefits that you find helpful but arent covered by Original Medicare.

What Parts Of Nursing Home Care Does Medicare Not Cover

Medicare doesnt cover most aspects of nursing home care. This includes custodial needs, such as bathing, eating or moving around. It also doesnt cover room and board for any long-term nursing home stay, including hospice care or the cost of a private room. Lastly, Medicare wont cover your skilled nursing facility stay if its not in an approved facility, so its important to know what institutions it has approved in your area.

Recommended Reading: Can You Get Hearing Aids With Medicare

Misconception : Is It True That If I Apply For Medicaid The Federal Government Will Pay For Everything

Not exactly. Medicaid is funded jointly by the state and federal government however, Medicaid is generally run by the state you live in, not the Federal government.

For those who meet the income and asset guidelines to apply for Medicaidand are also 65 or older and qualify for Medicare dual coverage is established. In instances when Medicare typically provides coverage, Medicare covers costs for services first.

Medicaid is in fact responsible for covering nursing home care past the point of Medicare coverage. Elder law attorney and Partner Joshua Beisker of Underberg & Kessler LLP explains that long-term care costs make up about a quarter of all health care expenses picked up by Medicaid, with hospital care, physician services, and prescription drug costs accounting for the rest. Federal rules require state Medicaid programs to cover certain mandatory services, such as hospital and physician care, laboratory and x-ray services, home health services, and nursing home care for adults.

Beisker adds that Medicaid covers more than 60 percent of all nursing home residents and roughly 50 percent of costs for long-term care services and supports. He also explains that Medicaid does not provide health care directly. The large majority of Medicaid beneficiaries are covered through private managed care plans. For others, state Medicaid programs pay hospitals, doctors, nursing homes, and other health care providers for covered services that they deliver to eligible patients.

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