Although nursing homes make much of their profits from payments from Medicare, it is not guaranteed that any nursing home stay will be paid for under this coverage. To qualify for Medicare coverage of a nursing home stay, there are several requirements and hoops that must be jumped through before coverage will be granted. Even then, many stays are only covered for 100 days and may still have personal costs involved. If you or a loved one need nursing home care, do not assume that it will be automatically covered under the Medicare system.
Limitations To Medicare Coverage Of Nursing Home Stays
There are specific limitations and requirements to obtaining Medicare for nursing home care. It is estimated that about half of all nursing home residents pay for their care from their own personal savings. Medicaid is available to pay for care for those who are financially unable to pay for their own care. Those who receive Medicare benefits may be able to used to pay for some of the costs, but it is important to understand the stipulations of these benefits.
- Medicare approved facility. The nursing home must be a Medicare certified facility to be eligible for Medicare payments for care.
- Must follow a qualified hospital stay. To receive Medicare benefits for nursing home care, the person must first been cared for at a hospital for a minimum of three days. Admission into the nursing home must be within 30 days of the hospital stay and for the same medical condition.
- Treatment must be ordered by a physician. A doctor must order that daily treatment or skilled care is needed for nursing home care to be covered and treatment must be received daily at the nursing home.
- Medical condition must be treatable. Medicare only covers nursing home care for acute patients that are expected to recover. It is not for long-term or custodial care.
- Partial payment on up to 100 days of care. If all these conditions are met, Medicare may cover up to 100 days of nursing home care per illness. However, after 20 days, the entire cost may not be covered. It can have a significant daily co-pay and can become the patient’s full responsibility after 100 days.
When the nursing home believes that a patient will no longer be eligible for Medicare benefits, they must give the patient 24-hour written notice before discharging them. Part of the notice will explain how they may appeal this decision through the Quality Improvement Organization (QIO). This needs to be executed as soon as possible to continue to receive benefits and many patients require the services of a qualified attorney to handle the appeal process. Although Medicare is available for nursing home care, do not automatically count on the fact that all nursing home stays will be covered. It is important to know what can be covered and when to ensure that those in need of care have alternative sources to turn to in case that Medicare will not cover their nursing home stay. Private insurance, Medigap coverage and other types of care outside of a nursing home are areas to explore for those who may need long-term care.