Medicare and Nursing Homes
Medicare Covered Nursing Homes
Medicare pays some nursing home costs for beneficiaries who require skilled nursing or rehabilitation services.
To be covered, you must receive the services from a Medicare certified skilled nursing home after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just before entering a nursing home. This is at least three days.
To learn more about Medicare payment for skilled nursing home costs, contact your Medicare Fiscal Intermediary or the State Health Insurance Assistance Program in your state by calling 1-800-MEDICARE.
*Medicare does not pay for long-term care stays, room and board, in a nursing home.
Most people, 65+ in the U.S., use the Original Medicare Plan to get health care. When you need a Skilled Nursing Facility, your health requires nursing or rehabilitation care by a staff to manage it, to observe it, and to evaluate its progress.
The types of skilled care that's available to you:
- Intravenous injections
- Physical therapy
- Speech therapy
- Occupational therapy
- Nursing help to improve your condition
- Nursing help to maintain your current condition and prevent it from getting worse
Skilled nursing and rehabilitation staff includes:
- Licensed practical and vocational nurses
- Physical and occupational therapists
- Speech-language pathologists
Skilled nursing care helps people's health condition to get better, function independently, and to learn to take care of one's own health needs.
Paying for Nursing Home with Medicare
The types of skilled care that Medicare covers requires the following conditions be met:
- You have Medicare Part A - Hospital Insurance - and have days left in your benefit period to use for skilled nursing care.
- You have a qualifying hospital stay - an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you but not including the day you leave.
- Your Skilled Nursing Facility admittance is within a short period of time (generally 30 days) of leaving the hospital.
- You have nursing and related service's needs.
- You require specialized rehabilitative services for mental illness or intellectual disabilities not provided for by the state.
- After you leave a skilled nursing facility and, if you have a need to re-enter the same or another one within 30 days, the 3-day qualifying hospital stay is not needed to qualify to receive additional benefits.
- Your doctor orders the services needed for skilled nursing care, requiring skills of registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists, and audiologists.
- You require medical social services to help with coping: social, psychological, cultural, and medical issues.
- Education needed on how to use health care and other resources, and help understanding the disease.
- The medical supplies and durable medical equipment you need like wheelchairs, hospital beds, oxygen, and walkers. You pay 20 percent of the Medicare-approved amount for the equipment.
- Pharmaceutical services that help with assurance of accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
- Dietary services and meals.
- You have emergency dental services and routine dental services.
- Room and bed maintenance services.
- Routine personal hygiene items and services.
There is no limit on how long you receive these as long as your doctor re-orders them every 60 days.
If you meet the conditions, Medicare will pay for some of your costs for up to 100 days. For the first 20 days, Medicare pays 100 percent of your costs. For days 21 through 100, you pay your own expenses up to $140.00 per day (as of 2013), and Medicare pays any balance. After 100 days, you pay 100 percent of costs.
Medicare Supplemental Insurance
Medigap is private health insurance and it helps pay for the gaps in Medicare like deductibles and co-insurances. It also helps pay for skilled nursing care in some cases.
*Others use employer group health plans or long-term care insurance to help cover nursing home costs.
What Medicare Will Not Pay
Residents in nursing homes must pay:
- Private room, unless medically needed
- Specially prepared food, beyond that generally prepared by the facility
- Telephone, television, radio
- Personal comfort items including tobacco products and confections
- Cosmetic and grooming items and services in excess of those included in the basic service
- Personal clothing
- Personal reading materials
- Gifts purchased on behalf of a resident
- Flowers and plants
- Social events and activities beyond the activity program
- Special care services not included in the facility's Medicaid payment
What happens if an individual stops getting skilled care in the nursing home facility or leaves? How does this affect Medicare skilled nursing care coverage? if a person needs more skilled care later on?
It depends on how long an individual's break in the skilled care facility lasts.
- If the break lasts for less than 30 days:
You don't need a new 3-day hospital stay to qualify for coverage of additional skilled nursing care.
Since your break in a skilled nursing care lasted for less than 60 days in a row, the period would continue.
How it works: Out of the nursing home for less than 30 days
Your mom received 10 days of Medicare-covered skilled nursing care after she's hospitalized for a broken hip. Medicare coverage ended when she stopped needing skilled care.
She chose to go home rather than pay for custodial care. After 10 days, her doctor decided she needed more skilled care for her broken hip to heal properly and she's readmitted to the nursing home. Medicare covers this nursing home stay.
Your mom has 90 days of coverage left in her benefit period.
- If the break lasts for at least 30 days but less than 60:
Medicare won't cover additional skilled nursing care unless the individual has a new 3-day qualifying hospital stay.
The new hospital stay need not be for the same condition that the person was originally treated for during the previous stay.
Since the break in the skilled nursing home care lasted for less than 60 days in a row, the current benefit period would continue. This means that the maximum coverage available is the number of unused skilled nursing care benefit days remaining in the current benefit period.
How it works: Out of the nursing home for at least 30 but less than 60 days
Your uncle received 20 days of Medicare covered skilled nursing care after he's hospitalized with a stroke. The Medicare coverage ended when he stopped needing skilled care.
He chose to stay in the nursing home and pay for 2 days of custodial care. Then he went home. After 34 days, his doctor readmitted him to the hospital for 4 more days because of his stroke.
Even though your uncle was out of the nursing home for more than 30 days, he had a new qualifying hospital stay. Medicare pays this nursing home stay. He has 80 days of coverage left in this benefit period.
- If the break in skilled nursing care lasts for - at least 60 days
Medicare won't cover additional skilled nursing care unless the patient has a new 3-day qualifying hospital stay.
The new hospital stay need not be for the same condition that someone's treated for originally.
Since the break in skilled care lasted for at least 60 days in a row, this would end the current benefit period and renew the skilled nursing benefits. This means that the maximum coverage available would be up to 100 days of nursing home benefits.
How it works: Out of the nursing home for at least 60 days
Your grandmother received 20 days of Medicare-covered nursing home care after she's hospitalized for back surgery. Her Medicare coverage ended when she no longer needed skilled care. She chose to go home rather than pay for custodial care.
After 65 days, she's hospitalized for 3 days due to a fall. Afterwards, she's admitted to a skilled nursing facility because she needed skilled care.
Since she was out of a skilled nursing facility for more than 60 days, her benefit period ended. Her new 3-day qualifying hospital stay starts a new benefit period. Medicare now covers up to 100 days of skilled nursing home care in this new benefit period.
Get State Help
Your State Health Insurance Program has counselors who can answer your questions about how to pay for nursing home care and whether there are government programs that can help with your expenses. Call 1-800-MEDICARE.
After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.
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