Nursing Home Care – What Medicare Doesn’t Cover

Those of us with aging parents or other loved ones with temporary or severe health issues are somewhat familiar with the basics of the hospital, rehab, and ongoing care aspects.  But when confronted with the realities, many of us feel like a deer in the headlights.  So many decisions and so many options at a time that we are also juggling a career and maybe a growing family.  Enter Healthcare Navigation, with this road map to help plan ahead for the discharge of a compromised relative or loved one.

About one year ago, Healthcare Navigation produced a video on Medicare Part A Basics, which you can click on the title in this paragraph or on the image below, and indicated that Medicare Part A covers skilled care in a nursing home. Now they want to elaborate on that topic since there are several issues to keep in mind due to the pandemic. 

Most covered stays, for example, immediately follow an inpatient hospital stay of three days or more. The benefit for an individual on Medicare Part A is defined as up to 100 inpatient skilled days in a benefit period but that does not necessarily mean that Medicare will cover for 100 days. Medicare covers when a patient is receiving skilled services, continues to recover from illness and/or injury, and requires care in an inpatient setting. Skilled services are provided by licensed professionals such as nurses, physical therapists, speech therapists and occupational therapists.

Medicare will not cover a stay when an individual remains in a nursing home because they are not safe to be at home or they need assistance with “activities of daily living” such as dressing, eating, toileting, transferring, bathing, or walking. These types of services are referred to as “custodial” and this type of care is paid for privately, with a long-term care policy or by Medicaid once someone has exhausted most of their assets.

This information is often new to the family of someone recently admitted to a skilled nursing facility after a hospitalization. It is not uncommon for family members to see the reference to 100 covered days under Medicare and assume they have the full 100 days to plan next steps. This is not often the case. Our advice is to stay in contact with that relative’s care team so that a projected date of when Medicare will stop paying for care doesn’t come as a surprise. Review of Medicare criteria for continued stay is typically handled by the nursing home staff. If you belong to an Advantage Plan, the plan usually has staff who will oversee continued stay decisions. A patient and family have the right to appeal a denial of ongoing Medicare coverage but in our experience, this typically results in extra days, not weeks, of continued benefits.

Finally, only the first 20 Skilled Nursing Facility days are covered entirely by Medicare. Days 21 to 100 have a copayment of $194.50 per day. Many people have Medicare supplements to help cover these costs. After 100 days, Medicare does not cover care in a Skilled Nursing Facility. Medicare beneficiaries are only eligible for more Skilled Nursing Facility days if they enter a new benefit period, which begins once someone has not used Part A services for 60 days and then has a subsequent hospital admission of three days or more. If you have an Advantage Plan, check that plan’s benefits.

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