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Medicare’s Limited Nursing Home Coverage

Posted by Aubrey Sizer | Mar 09, 2021 | 0 Comments

Many people believe that Medicare covers a patient's nursing home stay. Yet Medicare's coverage of nursing home care is quite limited. Medicare covers up to one hundred (100) days of “skilled nursing care” per illness, and a patient must meet several requirements before Medicaid covers the nursing home stay. The result of these requirements is that Medicare recipients are often discharged from nursing homes before they are ready.

For a nursing home stay to be covered by Medicare, a patient must enter a Medicare-approved “skilled nursing facility” or nursing home within thirty (30) days of a hospital stay that lasted at least three days. The care in the nursing home must be for the same condition as the hospital stay. In addition, the patient must need “skilled care.” Skilled nursing care means a physician must order the treatment, and a registered nurse, physical therapist, or licensed practical nurse must provide the treatment daily. Finally, Medicare only covers “acute” care instead of custodial care; this means Medicaid only covers care for patients who are likely to recover from their conditions. Medicaid will not cover care for patients who need ongoing help with performing everyday activities, such as bathing or dressing.

If a patient needs skilled nursing care to maintain his or her health status (or to slow his or her deterioration), then the care should be provided and is covered by Medicare. Also, patients often receive an array of treatments that do not need to be carried out by a skilled nurse but which may, in combination, require professional supervision. For example, the potential for adverse interactions among multiple treatments may need a skilled nurse to monitor a patient's care and status. In such cases, Medicare should continue to provide coverage.

Once a patient is in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing, rehabilitative services, and medically necessary supplies. Medicare covers 100 percent (100 %) of the costs for the first twenty (20) days. However, beginning on day 21 of the nursing home stay, the patient will owe a significant copayment ($185.50 a day in 2021). If the patient has a Medigap (supplemental) policy, it may cover the copayment. After 100 days, the patient is responsible for all costs.

If you are in a nursing home and the nursing home believes that Medicare will no longer cover you, it must give you a written notice of non-coverage. The nursing home cannot discharge you until the day after it gives you the notice. The notice should explain how to file an expedited appeal to a Quality Improvement Organization (QIO). A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries. If you receive such a notice, you should appeal right away. You will not be charged while waiting for the decision, but if the QIO denies coverage, you will be responsible for the cost. If the QIO denies coverage, you can appeal the decision to an Administrative Law Judge (ALJ). If you pursue an appeal, you should hire a lawyer to represent you.  For an article from the Center for Medicare Advocacy on nursing home discharges, click here.

The bottom line is that you cannot rely on Medicare to pay for your long-term care. Take the time to sit down with an elder law attorney to create a customized, comprehensive, long-term care plan. 

For more information on Medicare, click here.

About the Author

Aubrey Sizer

Aubrey Carew Sizer is a member of the Virginia State Bar with a practice focused on estate planning and elder law, specifically, long-term care planning, special needs planning for the disabled, guardianship and conservatorship, and probate, estate and trust administration.

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Attorney Sizer provides customized and affordable estate planning (including wills, living trusts, powers of attorney, and advance medical directives); elder law services (including long-term care planning, special needs planning for the disabled, and guardianships and conservatorships); probate, estate and trust administration (including advising executors and administrators of estates about post-mortem planning and the local probate process in Virginia), as well as general aging and disability advice in Northern Virginia, including but not limited to Arlington, Alexandria, Ashburn, Bristow, Burke, Centreville, Chantilly, Gainesville, Fairfax, Falls Church, Haymarket, Herndon, Leesburg, Manassas, Manassas Park, Reston, Springfield, Sterling, and throughout Loudoun, Prince William, and Fairfax counties.

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