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Does Medicare Pay For Skilled Nursing Home Care

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What About Inpatient Rehabilitation Care

Medicare & You: Nursing Home / Long-Term Care

Medicare will also cover rehabilitation services. These services are similar to those for skilled nursing, but offer intensive rehabilitation, ongoing medical care, and coordinated care from doctors and therapists.

The same types of items and services are covered by Medicare in a rehabilitation facility as with a skilled nursing facility. The same exclusions apply as well.

You may require inpatient rehabilitation for a brain injury that requires both neurological and physical therapies. It could also be another type of traumatic injury that affects multiple systems within the body.

The amount of coverage for inpatient rehabilitation is a little different than skilled nursing. Medicare Part A costs for each benefit period are:

  • Days 1 through 60: A deductible applies for the first 60 days of care, which is is $1,364 for rehabilitation services.
  • Days 61 through 90: You will pay a daily coinsurance of $341.
  • Days 91 and on: After day 90 for each benefit period, there is a daily coinsurance of $682 per lifetime reserve day .
  • After lifetime reserve days: You must pay all costs of care after your lifetime reserve days have been used.

What Nursing Home Services Does Medicare Cover

Medicare-covered nursing home services must be provided by, or under the supervision of, skilled professionals or technical staff. Nursing home personnel manage your care, evaluate your progress, and document the results of your treatment. Nursing home services must be ordered by your physician. Covered services include:

  • Semi-private room, which is a room you share with other patients
  • Meals
  • Services that are not deemed medically necessary or are not on your physician-ordered plan of care
  • A private room, unless your doctor says it is necessary for your condition
  • Ambulance transportation if you can safely be transported another way
  • Care provided at a facility that is not Medicare-certified

Frequently Asked Questions: Paying For Nursing Home Care When Money Runs Out

Paying for a nursing home when the money runs out can be a daunting and overwhelming situation. Hopefully, the billing office of the nursing home gives you adequate time to prepare to apply for Medicaid. Pre-estate planning is the best approach to knowing when money will run out and preparing well in advance for that scenario.

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When A State Can Recoup Benefits

After the Medicaid recipient dies, the state can try to recoup whatever benefits it has paid out. The home is usually the only major claimable asset. Currently, the state can only put a lien on it if it is part of the deceaseds probate estate. If the asset is jointly owned with a spouse or in a life estate or trust, then it can escape recovery.

In most states, the government can place a lien on the home after the death of both spouses, unless a dependent child resides on the property.

When Medicare Won’t Pay For Nursing Home Care

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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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Does Medicare Pay For Nursing Homes

En español | Medicare does not cover any type of long-term care, whether in nursing homes, assisted living facilities or peoples own homes.

Of course, Medicare covers medical services in these settings. But it does not pay for a stay in any long-term care facilities or the cost of any custodial care , except for very limited circumstances when a person receives home health services through a Medicare-approved agency.

Dual Eligibility For Medicare And Medicaid

Finally, keep in mind that it is possible to qualify for and be covered by both Medicare and Medicaid simultaneously. Such individuals are known as dually eligible beneficiaries. With dual eligibility, Medicare pays for covered medical services first and Medicaid is considered the payer of last resort. For example, Medicare covers qualifying health care costs for doctors appointments, durable medical equipment and hospitalizations while Medicaid covers qualifying remaining expenses, such as Medicare premiums and cost-sharing requirements and long-term care services.

Keep in mind that coverage and benefits available for dually eligible beneficiaries vary by state. To learn more, read Dual-Eligible Beneficiaries: Some Seniors Qualify for Both Medicare and Medicaid.

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How Long Medicare Pays For Skilled Nursing Care

Part A benefits cover 20 days of care in a Skilled Nursing Facility.

After that point, Part A will cover an additional 80 days with the beneficiarys assistance in paying their coinsurance for every day.

Once the 100-day mark hits, a beneficiarys Skilled Nursing Facility benefits are exhausted.

At this point, the beneficiary will have to assume all costs of care, except for some Part B health services.

Medicaid Eligibility For Nursing Home Care

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Medicaid coverage, like many other financial assistance programs, is dependent on a variety of factors such as age, financial status, assets, and level of care. If you need assistance for long-term nursing home care, you should check to see if you meet the Medicaid eligibility requirements in the state that youre currently residing in. Typically, one of the requirements of eligibility is that a majority of your income needs to be used to pay for the cost of your nursing home.

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How Much Will Medicare Cover

Medicares coverage for skilled nursing facilities is broken down into benefit periods. A benefit period begins the day you are admitted as an inpatient to the hospital or skilled nursing facility.

Different amounts are paid throughout the benefit period. The benefit period ends when 60 days in a row have passed without a need for hospital or skilled nursing care. If you go back to the hospital after that 60-day window, a new benefit period begins.

Here are the costs that apply throughout the benefit period:

  • Days 1 through 20: Medicare covers the entire cost of your care for the first 20 days. You will pay nothing.
  • Days 21 through 100: Medicare covers the majority of the cost, but you will owe a daily copayment. In 2020, this copayment is $176 per day.
  • Day 100 and on: Medicare does not cover skilled nursing facility costs beyond day 100. At this point, you are responsible for the entire cost of care.

While you are in a skilled nursing facility, there are some exceptions on what is covered, even within the first 20-day window.

There are some additional rules about Medicare coverage that you should know, including:

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.

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Medicare Advantage Nursing Home Benefits

If you have Medicare Advantagealso known as Medicare Part Cor any other type of Medicare-approved health insurance plan, the CMS says that the individual plan dictates whether any nursing home care coverage is provided and, if so, to what extent.

However, the CMS also says that most plans will not contribute to this type of extended care unless a nursing home has a contract with a particular plan.

Medicare Coverage Requirements For Skilled Nursing Facility Care

How Does Medicare Cover Skilled Nursing?

SNF care is nursing and therapy that can only be performed or supervised by professionals or technical personnel. Medicare Part A may help cover SNF care in certain conditions for a limited time if all of these conditions are met:11

  • You have Part A and have days left to use in your Medicare
  • You have a qualifying hospital stay
  • Your doctor decided that you need daily skilled care
  • The SNF where you get skilled services is certified by Medicare
  • You need these skilled services for a medical condition thats either:
  • A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital
  • A condition that started while receiving care in the SNF for a hospital-related medical condition

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Patient Criteria For Medicare Rehab Coverage

In addition to the benefit period rules above, a beneficiary must meet all the following requirements:

  • The beneficiary has Medicare Part A and days left in their benefit period available to use.
  • The beneficiary has a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more, starting with the day the hospital admits them as an inpatient, but not including any outpatient or observation days or the day they leave the hospital.
  • Following a qualifying hospital stay, a beneficiary must enter the skilled nursing facility within a short period of time of being discharged.
  • The beneficiarys doctor must order skilled nursing care, which requires the skills and oversight of professional personnel .
  • The beneficiary requires skilled care on a daily basis and the specific services needed must be ones that can only be provided in a SNF on an inpatient basis.
  • The beneficiary must need skilled services for the medical condition that was treated during their qualifying three-day hospital stay or a related condition.
  • The skilled services a doctor has prescribed must be reasonable and necessary for the diagnosis or treatment of the beneficiarys eligible condition.
  • Who Pays For Long

    Medicare doesnt pay anything toward the considerable cost of staying in a nursing home or other facility for long-term care.

    So who or what does? Here are some options.

    • Private pay: Many individuals and families simply pay out of pocket or tap assets such as property or investments to finance their own or a loved ones nursing home care. If they use up those resources, Medicaid may become an option.
    • Long-term care insurance: Some people have long-term care insurance that might pay, depending on the terms of their policies.
    • The VA: Military veterans may have access to long-term care benefits from the U.S. Department of Veterans Affairs.
    • Medicaid: The state and federal health care program that provides coverage to low-income people who qualify pays a considerable portion of Americas nursing home bills. Medicaid eligibility varies by state but requires strictly limited income and financial assets.

    Many Americans who are in need of long-term care apply after spending down their resources to the point of qualifying. Contact your State Health Insurance Assistance Program for information on eligibility.

    Editor’s note: This article was originally published on Jan. 1, 2014. It has been updated with the latest information regarding Medicare coverage in 2020.

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    Does Medicare Cover Home Instead

    Home instead is a private company that provides senior care services to help with a variety of issues. The costs for Home Instead care vary some insurance covers home care, Medicare doesnt.

    However, if there is a medical need for care, Medicare will pay for services at home. Medicare wont cover things like live-in caregivers, visiting angels, or other custodial services.

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    For a beneficiary to extend healthcare services through SNFs, the patients must undergo the 3-day rule before admission. The 3-day rule ensures that the beneficiary has a medically necessary stay of 3 consecutive days as an inpatient in a hospital facility. This doesnt include the day of the patients discharge, any outpatient observations, or the time spent in the emergency room.

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    Medicare And Medicaid Basics

    Both Medicare and Medicaid are overseen by the Centers for Medicare & Medicaid Services . These programs are often confused, but they are very different. The most important differences are the ways in which they are funded/administered and the purpose each serves.

    Medicare is a federal health insurance program for seniors, certain younger individuals with disabilities and people with end-stage renal disease. Like private health insurance plans, Medicare does not cover long-term care of any kind. This includes in-home care, assisted living, memory care and nursing home care. However, there are exceptions for the short-term provision of similar services. For example, Medicare will cover stays in skilled nursing facilities for short-term rehabilitation following a qualifying hospital stay.

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    Medicaid is a jointly funded federal and state medical assistance program that provides health coverage for low-income Americans with few assets. Unlike Medicare, Medicaid programs for the elderly and disabled do cover various long-term care services. Essentially, the Medicaid long-term care program ensures that people who cannot afford the high level of care they need are still able to receive it. Seniors who meet their states financial eligibility requirements and have a documented medical need for nursing home level care should qualify for Medicaid coverage of their nursing home costs.

    Guidelines To Medicare Coverage For Skilled Nursing Facilities

    Home / FAQs / Medicare Coverage / Guidelines to Medicare Coverage for Skilled Nursing Facilities

    There are some specific Medicare coverage guidelines that pertain to Skilled Nursing Facility services. Skilled nursing services are specific skills that are provided by health care employees like physical therapists, nursing staff, pathologists, and physical therapists. Guidelines include doctor ordered care with certified health care employees. Also, they must treat current conditions or any new condition that occurs during your stay at a Skilled Nursing Facility. Below, well go over what you need to know about Medicare coverage for Skilled Nursing Facilities.

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    When Does Medicare Pay For Nursing Care

    To qualify for nursing home coverage under Medicare, you must meet the following conditions:

    • Recent hospital stayYour care in a skilled nursing or rehabilitation facility bust begin within 30 days of an inpatient hospital stay of at least three days .
    • Physician-prescribed need:Your physician must prescribe nursing home care for daily skilled nursing or physical rehabilitation. If you do not need skilled care every day, Medicare wont cover nursing home care, though it may cover home care.
    • Medicare-approved facility:Inpatient skilled nursing or rehabilitation care must be provided by a Medicare-certified facility.
    • Improving condition:Medicare covers nursing home care only as long as you are getting better. Once your doctor, the facility and Medicare have found that your condition is stable, Medicare will no longer cover inpatient nursing home care.

    Paying For Skilled Nursing Facility Care

    When Medicare Won

    There are several programs that may help you cover your out-of-pocket costs for skilled nursing care. You can call your state Medicaid office for more information about these programs and whether they are right for you.

    State Medicare Savings Programs can help pay premiums, deductibles, copayments and prescription drug costs if you meet certain conditions. You must have limited resources in checking or savings accounts, stocks and bonds to qualify.

    Medicaid is a joint state and federal program that helps with medical costs for some people who have limited income and financial resources. It may offer benefits for services not covered by Medicare.

    In some cases, PACE, or Program of All-inclusive Care for the Elderly, may be an alternative if the services you require can be performed in the home, community or a local PACE center.

    PACE is a joint Medicare and Medicaid program that helps people meet health care needs in their community instead of going into a nursing home or other care facility. You may be required to use a PACE-preferred doctor when you enroll.

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    What Are Nursing Home Services

    Nursing home services encompass a wide range of health and medical services and assistance with activities of daily living like eating, bathing, and getting dressed. Nursing homes provide 24-hour supervision from paid staff who serve as primary caregivers. The majority of nursing home services are custodial in nature, but Medicare-certified nursing homes also can provide the highest level of skilled care available outside of the inpatient hospital setting.

    Medicare’s Limited Nursing Home Coverage

      Many people believe that Medicare covers nursing home stays. In fact Medicare’s coverage of nursing home care is quite limited. Medicare covers up to 100 days of “skilled nursing care” per illness, but there are a number of requirements that must be met before the nursing home stay will be covered. The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.

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      In order for a nursing home stay to be covered by Medicare, you have to meet the following requirements:

      Note that if you need skilled nursing care to maintain your status , then the care should be provided and is covered by Medicare. In addition, patients often receive an array of treatments that don’t need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient’s care and status. In such cases, Medicare should continue to provide coverage.

      You cannot rely on Medicare to pay for your long-term care. Contact your attorney to create a long-term care plan. To find a qualified elder law attorney, .

      For more information on Medicare, .

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