Understanding Medicare Coverage for Nursing Home Costs
Medicare can cover some nursing home costs for beneficiaries who need skilled nursing or rehabilitation services. In order to be eligible for this insurance, the care needs to be offered by a skilled nursing facility certified by Medicare following a hospital stay that meets the requirements. A qualifying hospital stay requires at least three consecutive days in a hospital before transitioning to a nursing home.
Remember, Medicare does not offer coverage for long-term care or housing in a nursing facility for stays that go past the skilled nursing care period.
Who Uses Medicare for Skilled Nursing Facilities?
Most people over 65 in the U.S. are enrolled in the Original Medicare Plan to receive healthcare services. When a beneficiary requires a skilled nursing facility (SNF), it is usually because their health condition necessitates nursing or rehabilitation care managed by professional staff. The care provided is monitored and evaluated regularly to ensure that the patient’s health improves or is maintained to prevent deterioration.
Types of Skilled Care Covered by Medicare
Medicare covers various types of skilled care, including but not limited to:
- Intravenous (IV) injections
- Physical therapy
- Speech therapy
- Occupational therapy
- Nursing assistance to improve or maintain health conditions
Who Provides Skilled Nursing Care?
Skilled nursing care is administered by a range of healthcare professionals, including:
- Registered nurses (RNs)
- Licensed practical nurses (LPNs) and vocational nurses
- Physical therapists
- Occupational therapists
- Speech-language pathologists
- Audiologists
- Skilled nursing care aims to help patients recover from illnesses or surgeries, regain independence, and manage their health needs effectively.
Eligibility Requirements for Medicare to Cover Skilled Nursing Care
For Medicare to cover skilled nursing care, several conditions must be met:
Medicare Part A Enrollment
The beneficiary must have Medicare Part A (Hospital Insurance) with available days left in their benefit period for skilled nursing care.
Qualifying Hospital Stay
A hospital stay of at least three consecutive days is required, beginning with the day of admission but excluding the discharge day.
Timely Admission to SNF
Admission to the skilled nursing facility should generally occur within 30 days of discharge from the Hospital.
Medical Necessity
The patient must have medical needs for skilled nursing, related services, or specialized rehabilitative services.
Physician’s Order
A doctor must order skilled nursing care services, specifying that the care requires the expertise of registered nurses, physical therapists, occupational therapists, or speech-language pathologists.
Additional Services and Equipment
Medicare also covers certain medical supplies, durable medical equipment (e.g., wheelchairs, hospital beds), pharmaceutical services, dietary services, and more. Beneficiaries may pay 20% of the Medicare-approved amount for equipment.
If all these conditions are met, Medicare can cover some costs for up to 100 days in a skilled nursing facility. Medicare fully covers the first 20 days, while the beneficiary is responsible for copayments for days 21 to 100. After 100 days, the beneficiary must pay all costs out-of-pocket.
What Medicare Won’t Pay For
While Medicare covers many services in a skilled nursing facility, some costs will not be covered. These include:
- Private rooms (unless medically necessary)
- Specially prepared foods beyond the facility’s standard meals
- Personal comfort items such as telephones, televisions, radios, tobacco products, and grooming items
- Personal clothing and reading materials
- Social activities beyond the standard programs offered
- Special care services are not included in the facility’s basic service
Medicare and Coverage Scenarios
Coverage After a Break in Skilled Care
If a patient stops receiving skilled care or leaves the nursing home, Medicare coverage can be affected depending on the length of the break:
Break Less Than 30 Days
If the patient returns to a skilled nursing facility within 30 days, a new 3-day hospital stay is not required to resume coverage. The current benefit period continues.
Break Between 30 and 60 Days
If the break lasts from 30 to 60 days, an additional 3-day hospitalization is necessary to be eligible for further coverage. The maximum coverage available will be based on the remaining days in the current benefit period.
Break of 60 Days or More
If the break lasts 60 days or more, the current benefit period ends, and a new 3-day hospital stay is needed to qualify for a new benefit period, which allows up to 100 days of coverage.
Additional Coverage Options
Medicare Supplement Insurance (Medigap) and other private health insurance plans may assist in covering expenses that Medicare does not pay for, like deductibles and coinsurance. Some beneficiaries may also use employer group health plans or long-term care insurance to cover nursing home costs.
Medicare provides substantial coverage for skilled nursing care in specific circumstances, but it is essential to understand the eligibility criteria and the limitations. Additional insurance or personal funds may be required for long-term care needs and services beyond what Medicare covers. Beneficiaries should consult with Medicare or their insurance providers to understand their coverage options fully.
