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Medicare coverage of nursing home care

Medicare coverage

Question:

 

Does Medicare really pay for nursing home care?

 

Answer:

 

The answer is a bit more complicated than a simple yes or no. Unfortunately – despite what many people believe – Medicare will not cover all nursing home costs. As of 2010, Medicare will pay for up to 100 days of skilled nursing care in a facility that is certified by Medicare IF all of the following conditions are met:

 

  • Placement in a skilled nursing facility (SNF) is within 30 days of a hospital stay.

 

  • The hospital stay lasted at least three days – but that doesn’t include the day of discharge, so it’s really four days.

 

  • The care is medically necessary, which is usually defined as skilled-nursing or skilled-rehab care.

 

  • The skilled care is directly related to the medical condition that resulted in the hospitalization.

 

If all of these conditions are met, Medicare may cover up to 100 days of skilled care. But remember, the care must be skilled, rather than chronic or custodial care. Skilled care must be medically necessary and prescribed by a physician. The skilled care must improve or maintain the patient’s condition and prevent it from further deterioration. The care requires registered nurses, physicians and professional therapists who manage, observe and evaluate the patient’s condition. Under this scenario, Medicare will pay 100 percent of your parent’s first 20 days in a nursing home. On average, most people need no more than 20 days of skilled care. Where they run into trouble is when they need additional days of “chronic care,” which Medicare won’t cover.

 

If your parent needs additional “skilled” care beyond 20 days, Medicare will cover all but $137.50, which is your hefty daily co-pay, for days 21 through 100. The good news is that most Medigap policies (supplemental insurance) will cover the co-pay. But after 100 days, there will be no Medicare payments or Medicare supplements.

 

A beneficiary can collect under this benefit several times over a lifetime. How? A benefit period is not determined on an annual or lifetime basis. It begins when your parent enters a hospital and ends when there has been a break of at least 60 consecutive days since inpatient hospital or skilled nursing care was provided.

 

The two most important things to remember are: always carry a Medigap policy which will cover the gap between what’s charged for the care and what Medicare will cover; and never assume that Medicare will cover nursing home care. If, during a hospital stay, your parent is told that he or she needs to be transferred to a nursing home, make sure you talk with the physician to find out if he or she is prescribing skilled care. If so, also make sure that the facility has been certified by Medicare so that your parent can receive the coverage that Medicare does provide.

 

If you have any questions, be sure to ask to speak to the hospital’s discharge planner prior to discharge. Medicare also has an excellent website that features their downloadable handbook, “Medicare Coverage of Skilled Nursing Facility Care” at medicare.gov. You can also call them at 1.800.633.4227.

 

 

 

 

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