Thursday, June 16, 2022

Does Medicare Pay For Skilled Nursing

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â ï¸?Warning! – When Medicare DOES NOT Pay for Skilled Nursing Care!â ï¸?

Medicare Part A will help pay for skilled nursing care for up to 100 days at a time. Called a “benefit period,” these benefits reset when you’ve stopped receiving skilled nursing care for 60 consecutive days.

Your Part A benefits work like this:

  • Medicare Part A pays all of your costs for the first 20 days. You pay nothing.

  • For days 21-100, you are responsible for a daily $176 coinsurance in 2020.

  • If you require skilled nursing care longer than 100 consecutive days, you are responsible for all costs.

There are other additional conditions to keep in mind. Be sure to ask your doctor or health care provider about whether the services they provide will be covered by Medicare.

How Medicare Measures Skilled Nursing Care Coverage

Medicare measures the use and coverage of skilled nursing care in benefit periods. This is a complicated concept that often trips up seniors and family caregivers. Each benefit period begins on the day that a Medicare beneficiary is admitted to the hospital on an inpatient basis. Time spent at the hospital on an outpatient or observation basis does not trigger the beginning of a benefit period.

Once a benefit period begins, a beneficiary must then have a qualifying three-day inpatient hospital stay in order be eligible for any coverage of rehab care in a skilled nursing facility. A benefit period ends when the beneficiary has not received inpatient hospital or SNF care for 60 consecutive days. Once a benefit period ends, a new one can begin the next time the beneficiary is admitted to the hospital. There is no limit to the number of benefit periods a beneficiary can have.

Does Medigap Pay For Skilled Nursing Care

Yes, there are several Medigap plans that pay the coinsurance for skilled nursing facility care. Also known as Medicare Supplement Insurance, you get this coverage with Medigap Plans C, D, F, G, M, and N. In addition, Plan K covers 50 percent and Plan L pays 75 percent of the Part A coinsurance.

Comparing Medigap plan options is easy with our Find a Plan tool. Just enter your location and coverage start date to review Medicare plans in your area.

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Does Medicare Pay For Nursing Home Care

If you have had a qualifying inpatient hospital stay and your doctor orders an additional period of treatment in a skilled nursing facility, Medicare Part A generally covers allowable expenses. Your Part A nursing home benefit usually covers:

  • A semi-private room
  • Medical equipment and devices you use during your hospital stay
  • Ambulance transportation to and from the facility

There are costs for a covered stay in a skilled nursing facility . In 2019, you pay no coinsurance for days 1 through 20, $170.50 per day for days 21 through 100, and all nursing home costs for your care after the 100th day.

Medicare does not, however, pay any nursing home costs for long-term care or custodial care. If you need unskilled care for activities of daily living, care for an extended period of time, or care that is not reasonably expected to improve your condition within a limited timeframe, Medicare will not cover it.

What Is Custodial Care

How Does Medicare Cover Skilled Nursing?

Custodial carerefers to the nonmedical help you may need to go about your daily life. Examples of this assistance include receiving help to get dressed, get out of bed or use the bathroom. Others include meal preparation or medication management.

Assisted living facilities offer custodial care to residents who dont require round-the-clock skilled medical care at skilled nursing facilities, also called nursing homes.

According to the National Center for Assisted Living, there are more than 800,000 Americans residing in assisted living.2 The majority are 85 and older. Some common medical conditions of residents include high blood pressure, arthritis, Alzheimers or dementia, heart disease or depression.

For those who need additional care, skilled nursing facilities provide skilled nursing and therapy services to treat, manage and observe medical conditions and evaluate care.

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Debunking Medicares Improvement Standard

For many years, senior rehab facilities told their patients that Medicare would cease paying for skilled nursing care if their health stopped improving or had plateaued within their covered benefit period. However, Jimmo v. Sebelius, a 2013 federal court settlement, prompted the Centers for Medicare and Medicaid Services to make an admission about this policy:

Medicare has never supported the imposition of this Improvement Standard rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patients condition. Thus, such coverage depends not on the beneficiarys restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.

The current Medicare Benefit Policy Manual has reflected these clarifications since 2014, but some senior rehab facilities havent adapted to help chronic patients get access to the coverage they are eligible for. Furthermore, many business offices rely on software programs to manage their billing, and it is possible that some of those programs havent caught up.

Make Sure You Have The Coverage You Need

As you approach retirement, you need to consider all your options. You’ll have choices about the types of coverage available to you, so look at your lifestyle, your retirement savings and any plans you’ve made around long-term care when selecting an insurance policy.

Once you’ve reviewed your options, you’ll be able to make an informed choice about the best approach for you and your family.

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Unlimited Skilled Nursing Benefit Periods

Once you are out of skilled nursing for 60 days, your SNF benefit period ends, but you may become eligible again for another SNF benefit period after a qualifying hospital stay of 3-days. There is no limit on the number of benefit periods available to a Medicare beneficiary as long as the Medicare requirements are met.

In other words, a person could potentially keep going into Medicare covered skilled nursing care every 100 days after a 60-day break as long as it is preceded by a qualifying hospital stay of 3-days. While repeat 100 day stays in a skilled nursing facility are not likely, that does give an idea of the level of incredible care available to a Medicare beneficiary.

What Does Medicare Cover For Nursing Homes

Does Medicaid or Medicare Pay for Skilled Nursing Facilities?

Medicare is a federal insurance program that provides health insurance to people, including many North Carolinians, over the age of 65, no matter their income. The program also serves younger disabled people, kidney dialysis patients, and individuals with Lou Gehrigs disease.

Will Medicare cover my nursing home expenses?

A nursing home is a facility that provides short-term and long-term care to people who cannot be cared for comfortably at home. This could be due to physical, emotional or mental problems. Staff members at the facility may assist patients with bathing, dressing, eating and other daily activities.

The unfortunate reality is that Medicare will only pay for a nursing home in very limited circumstances. According to Medicare policies, the insurance program will pay nursing home charges under these conditions:

  • the care is considered medically necessary
  • the facility care is only needed for a limited period of time
  • the care is provided by a Medicare-certified, skilled facility that is qualified to provide rehabilitation therapies and,
  • the patient enters the nursing home after a qualifying inpatient hospital stay of three days or more.

How much will Medicare pay?

How else can I pay for a nursing home?

Long-term Care Insurance

Personal Resources

Medicaid

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Skilled Nursing Facilities Rules More Complex

The rules involving Medicare and nursing homes or skilled nursing facilities are more complex.

Original Medicare and Medicare Advantage will pay for the cost of skilled nursing, including the custodial care provided in the skilled nursing home for a limited time, provided 1) the care is for recovery from illness or injury not for a chronic condition and 2) it is preceded by a hospital stay of at least three days.

For the first 20 days, Medicare will pay for 100% of the cost. For the next 80 days, Medicare pays 80% of the cost. Skilled nursing beyond 100 days is not covered by Original Medicare.

Individuals who have a Medicare Advantage plan have at least the same coverage as mentioned above, and perhaps, have additional coverage. In addition, persons with certain types of Medicare supplemental insurance can get additional assistance towards defraying the cost of nursing home/skilled nursing care. Some plans will cover 100% of the coinsurance payment required by Medicare. This means that between Medicare and the Medigap plan, 100% of the cost of skilled nursing for 100 days will be covered.

Whats A Qualifying Hospital Stay

Another important rule: You must have had a qualifying hospital stay, meaning you were formally admitted as an inpatient to the hospital for at least three consecutive days. You cannot have been in observation status.

In both cases you are lying in a hospital bed, eating hospital food and being attended to by hospital doctors and nurses. But time spent under observation does not count toward the three-day requirement for Medicare coverage in a skilled nursing facility.

When you enter the hospital, ask if you are being officially admitted or for observation. If the latter, you may want to appeal to your doctor to see if you can be switched to inpatient status. Two more things to note about the three-day rule:

  • Medicare Advantage plans, which match the coverage of original Medicare and often provide additional benefits, often dont have those same restrictions for enrollees. Check with your plan provider on terms for skilled nursing care.
  • Skilled nursing facilities are the only places that have to abide by the rule. If youre discharged from the hospital to another kind of facility for ongoing care, such as a rehabilitation hospital, Medicare provides coverage under different rules.

If you qualify for short-term coverage in a skilled nursing facility, Medicare pays 100 percent of the cost meals, nursing care, room, etc. for the first 20 days. For days 21 through 100, you bear the cost of a daily copay, which was $170.50 in 2019.

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Does Medicare Advantage Cover Skilled Nursing Facilities

While none of the Medicare plans cover the cost of living in nursing homes or assisted living facilities, Medicare Part A and Medicare Advantage do cover a stay in a skilled nursing facility.

When Would You Need Skilled Nursing Care?

Skilled services are often needed for an illness or an injury that requires daily, inpatient care. You receive these services until doctors clear you to return home or to a long-term care facility. Examples of a long-term care facility include a nursing home or an assisted living facility.

Conditions that require a stay in a skilled nursing facility include strokes, broken bones, wound care or post-surgery care. You may also need to transition to a skilled nursing facility after being hospitalized for an illness so that you can work with nurses, physical therapists and occupational therapists before you return home.

When Does Medicare Advantage Cover Skilled Nursing Care?

Medicare Part A and Medicare Advantage will cover a skilled nursing facility stay for up to 100 days as long as you meet a list of criteria.

Those criteria include:

  • Skilled nursing services and/or therapy services that are required on a daily basis as ordered by a doctor.
  • Care for a medical condition that was treated during a three-day hospital stay.
  • Your skilled nursing facility is a Medicare-approved facility.

Work with your doctor, your healthcare providers, your social worker and your family to find the right facility to meet your needs.

Does Medicare Pay For Skilled Nursing Care

The Medicare 100 Days Reset, Exhaustion &  60 Day Benefits ...

Yes, but there are several conditions and stipulations, and it does not cover an indefinite period of time. First, be aware that skilled nursing is defined by the CMS as medically necessary care that can only be provided by, or under the supervision of, skilled or licensed medical personnel.

The need for skilled nursing care must be predicated by an admitted hospital stay of at least three days or longer, and admittance into post-hospital care must occur within 30 days of the hospital stay. Medicare benefits are focused on rehab, not indefinite long-term care.

Post hospital stay, Medicare covers the full cost of medically necessary skilled care for the first 20 days . After that, if a patient is approved to stay beyond 20 days, their co-pay from day 21 to 100 is $185.50 per day, as of this writing. After 100 days, Medicare coverage stops, and the beneficiary is responsible for 100 percent of the cost.

This 100-day cap can be reset in some situations if at least 60 days pass between occurrences that require a hospital stay.

  • Not all patients receive the full 100 days of care. The patient must continue to make progress in rehabilitation during the stay. If their condition plateaus, Medicare coverage of the rehab stay usually ends.

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Who Is Eligible For Skilled Nursing

  • You are enrolled in Medicare Part A and have days remaining to use in your benefit period.
  • You have a qualifying three-day inpatient hospital stay.
  • Your doctor has determined you need daily skilled nursing care.
  • Your skilled nursing care is administered in a Medicare-certified SNF.
  • A hospital-related medical condition treated during your qualifying hospital stay, even if it wasnt the reason you were admitted to the hospital.
  • A condition that started while you received care in the SNF for a hospital-related medical condition.

Medicare Coverage Requirements For Skilled Nursing Facilities

There are specific requirements that beneficiaries must meet to qualify for Medicare coverage for Skilled Nursing Facilities. The patient must have been an inpatient of a hospital facility for a minimum of three consecutive days. The patient must go to a Skilled Nursing Facility that has a Medicare certification within thirty days of their hospital discharge.

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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 deceased’s 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.

What If I Am Hospitalized More Than Once During A Calendar Year

FAQâWhat Does Medicare Pay for in a Nursing Home?

Example Situation: I had a broken hip six months ago and used Medicare benefits for rehab following my surgery. I then had a 5-day hospitalization for a urinary tract infection with sepsis. The doctor and the therapist want me to go to rehab again will my Medicare benefit cover this?

The Medicare website explains:

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 doesnt need to be for the same condition that you were treated for during your previous stay.

In addition, Medicare insurance benefits reset under certain conditions. If the patient has had a 60 day period without being hospitalized or in a skilled nursing facility receiving skilled services since their last use of their Medicare benefits. A new Medicare stay can begin under the qualifying guidelines.

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How To Get Approved For In

There are a handful of steps and qualifications you need to meet to have your in-home care covered by Medicare. It starts with the type of help your doctor says you or your loved one needs and includes other aspects of care.

You cant simply decide that you prefer your nursing care and other therapy needs in your home. You must meet the qualifications for in-home care, and they include the following:

You must be under the care of a doctor:

The primary step in getting approved for in-home care is that you and the nursing plan must be under the care of a Medicare-approved doctor. This doesnt mean that the doctor will be at every visit. A home health nurse specialist will administer your plan, which your will create and regularly review.

Youre homebound:

This is when youre unable to leave your house for treatment. Homebound patients require assistance from a person or piece of durable medical equipment such as a walker or wheelchair to get around the home or to get to services outside the home. Immobile people are considered homebound as well. A doctor can deem that youre homebound if he or she believes that your illness or condition could get worse if you left the home.

You doctor certifies that you need home care:

You dont need round-the-clock care:

Your in-home care comes from an approved home health agency:

MORE ADVICE

How Much Does Home

Skilled nursing care at your home can cost you $20 per hour. In-home care usually costs around $4,000 per month. The cost will vary from state to state.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

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What Is The Benefit Period For Skilled Nursing Facility With Medicare

Benefit periods are how Skilled Nursing Facility coverage is measured. These periods begin on the day that the beneficiary is in the healthcare facility on an inpatient basis. This period ends when the beneficiary is no longer an inpatient and hasnt been one for 60 consecutive days.

A new benefit period may begin once the prior benefit period ends, and the beneficiary receives another admission to a healthcare facility. One keynote to remember is that a new benefit period is not each calendar year or change to the patients diagnosis or health condition.

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