Long Term Care Benefits
Medicare is the primary medical care insurance for a large number of seniors. Many are shocked to discover that Original Medicare , also called Traditional Medicare, does not cover costs for most types of long-term care, including Alzheimers and dementia care. When it does pay, it is only in a very limited capacity. While Traditional Medicare is not a long-term care solution, there are benefits for seniors with recoverable conditions on a short-term basis. Also, as mentioned previously, some Medicare Advantage Plans now offer some home and community based long-term care benefits under specific circumstances.
Skilled Nursing FacilitiesMedicare will pay for 100% of the cost of care up to 20 days at a skilled nursing facility and approximately 80% of the cost up to 80 more days. The care must be for recovery following an in-patient hospital stay.
Assisted Living CommunitiesMedicare does not cover any cost of assisted living. It will pay for most medical costs incurred while the senior is in assisted living, but will pay nothing toward custodial care or the room and board cost of assisted living. Some Medicare Advantage plans may pay for personal care assistance for persons residing in assisted living or memory care, but will not contribute towards the cost of room and board.
Adult Day CareOriginal Medicare does not pay for adult day care services, but some Medicare Advantage plans may cover the cost.
Required Prior Hospital Stay
Your stay in a skilled nursing facility must follow at least three consecutive days, not counting the day of discharge, in the hospital. And you must have been actually “admitted” to the hospital, not just held “under observation.”
In addition, your stay in the nursing facility must begin within 30 days of being discharged from the hospital. If you leave the nursing facility after Medicare coverage begins, but are readmitted within 30 days, that second period in the nursing facility will also be covered by Medicare.
Does Medicare Cover Care In A Skilled Nursing Facility Or Nursing Home
Medicare Part A covers up to 100 days in a skilled nursing facility after a qualifying hospital stay. The Part A deductible covers the first 20 days per benefit period. After that, you pay a share of the cost for each additional day of your stay. You would start paying the full cost after 100 days.
Medicare does not cover long-term custodial care in a nursing home, though Medicaid or private long-term health insurance may. However, Medicare does continue to cover medical care for nursing home residents.
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Medicare Coverage Requirements For Skilled Nursing Facility Care
SNF care is nursing and therapy that can only be performed or supervised by professionals or technical personnel. Medicare Part A may help cover SNF care in certain conditions for a limited time if all of these conditions are met:11
- You have Part A and have days left to use in your Medicare
- You have a qualifying hospital stay
- Your doctor decided that you need daily skilled care
- The SNF where you get skilled services is certified by Medicare
- You need these skilled services for a medical condition thats either:
- A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital
- A condition that started while receiving care in the SNF for a hospital-related medical condition
How Long Will Medicare Pay For An Snf
After 100 days in any benefit period, you are on your own as far as Medicare Part A hospital insurance is concerned. Medicare will pay nothing after 100 days.
But if you later begin a new spell of illness , your first 100 days in a skilled nursing facility will again be covered. For more information on benefit periods and lifetime reserve days, see our article on Medicare Part A coverage.
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Nursing Homes That Accept Medicare
Even if you meet the Medicare eligibility criteria for nursing home coverage, Medicare will only cover costs if you go to a Medicare-approved facility.
If you are in hospital care, your doctor or social worker will be able to find a nursing home that meets your medical needs and is certified by Medicare. Your caregiver or hospital staff should also arrange your transfer to the nursing home.
Medicare also has helpful resources to help you find nursing homes that accept Medicare in your area.
Day Hosptial Stay Rule With Medicare Billing For Coverage In Skilled Nursing Facilities
For a beneficiary to extend healthcare services through SNFs, the patients must undergo the 3-day rule before admission. The 3-day rule ensures that the beneficiary has a medically necessary stay of 3 consecutive days as an inpatient in a hospital facility. This doesnt include the day of the patients discharge, any outpatient observations, or the time spent in the emergency room.
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Does Medicare Cover Nursing Homes
Medicare covers nursing home care only in instances where a doctor has determined you require daily, skilled nursing care for treating a hospital-related medical condition.
To be eligible for Medicare nursing home coverage you must have first had a qualifying hospital stay. Your nursing home care will be covered under your Medicare Part A benefits which cover hospitalization, skilled nursing care, lab tests, surgery, and home health care.
Medicare coverage for nursing home care is limited to 100 days and the patient must be receiving skilled care for recovery after an inpatient hospitalization.
Readmission To A Hospital
If you’re in a SNF, there may be situations where you need to be readmitted to the hospital. If this happens, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.
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What Does Medicare Cover When I Qualify For Skilled Nursing Care
The nursing facility care and services covered by Medicare are similar to what’s covered for hospital care. They include:
- a semiprivate room , or a private room if medically necessary
- all meals, including special, medically required diets
- regular nursing services
- special care units, such as coronary care
- drugs, medical supplies, treatments, and appliances provided by the facility, such as casts, splints, and wheelchairs, and
- rehabilitation services, such as physical therapy, occupational therapy, and speech pathology, provided while you are in the nursing facility.
The costs for staying in a skilled nursing facility for the first twenty days are covered 100% after that, there is a co-pay .
For How Long And How Much Does Medicare Pay For Nursing Home
Medicare will cover nursing home costs as follows:
- Days 1 to 20: Medicare pays for the full cost of the nursing home care received
- Days 21 to 100: For days 21 through 100, Medicare will cover the cost of skilled nursing care but you are required to copay $185.50 coinsurance per day
- Days 101+: Medicare does not cover skilled nursing care at a nursing home beyond 100 days. Once the benefit period ends the patient has to bear all costs
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Medicare Coverage Requirements For Skilled Nursing Facilities
There are specific requirements that beneficiaries must meet to qualify for Medicare coverage for Skilled Nursing Facilities. The patient must have been an inpatient of a hospital facility for a minimum of three consecutive days. The patient must go to a Skilled Nursing Facility that has a Medicare certification within thirty days of their hospital discharge.
Exhausted Part A Benefit
- For each benefit period, Part A covers up to 20 full days of care
- After that, Part A covers up to an additional 80 days, with the patient paying coinsurance for each day
Your Medicare Benefits has more information about patient coverage, costs, and care in a SNF.
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Medicare & Nursing Homes
Information in this section refers to original Medicare. If you have a Medicare Advantage Plan, you must check with your particular plan.
If you need help with understanding your health insurance, contact the Virginia Insurance Counseling & Assistance Program to find a counselor near you.
- Center for Medicare Advocacy, Inc. -CMA is a national non-profit group with a special focus on Medicare beneficiaries and their needs. Providing an array of information throughout the site, you may find the âTopicâ section particularly helpful.
- Medicare Rights Center – The Center is a national, nonprofit service organization focused on access to quality care for elders and individuals with disabilities. They provide counseling, advocacy, and educational programs. If you have questions about Medicare, you may find their national Helpline helpful.
- Medicare.gov – The Official U.S. Government Site for Medicare
- KePro â Handles complaints and appeals concerning services paid for by Medicare.
Terms to Know
Original Medicare Conditions to be Met
Original Medicare helps pay for nursing home care when the following are met:
Limits to Medicare Part A Coverage of Skilled Care
Medicare Part A coverage of skilled care in a Medicare certified skilled nursing facility is limited to 100 days and only the first 20 days are covered in full by Medicare. Here is how it works:
Possible Problems & What You Need to Know
Medicare Benefits And Long Term Care
What is Medicare?
Medicare is the federal health insurance system for persons:
- 65 years or older
- Under 65 with certain disabilities
- Of all ages with End Stage Renal Disease
You can enroll in Original Medicareor a Medicare Advantage Plan. The Medicare website provides information to Veterans and caregivers, including:
- Medicare eligibility tool
- Tips on selecting a Medicare plan
- How to get help paying Medicare costs
- Directory of Medicare-certified providers
Medicare Coverage For Skilled Nursing Facilities
As you age, you might suffer an ailment requiring time in a skilled nursing facility . Skilled nursing facilities are any medical facility where doctors, pathologists, physical therapists, and medically trained nurses are all required to give you the care you need to improve.
But you must coordinate with medical providers at a hospital first to get the okay from Medicare to stay in one of these facilities unless youre willing to pay 100% out-of-pocket. On top of that, your Medicare benefits will only pay for a limited stay in an SNF. This limited window in which you are eligible for benefits is called a benefit period.
The good news is that you can be eligible for more than one benefit period per year, but it can still get expensive if you arent careful. Below is the rundown on how benefits periods work for skilled nursing facilities.
Well explain how you can get the most out of your Medicare benefits and what you need to do to protect yourself from exorbitant out-of-pocket costs.
What Skilled Nursing Facility Costs Does Medicare Cover
Medicare can cover many of the services you receive in a skilled nursing facility, such as:
- A semiprivate room and meals
- Skilled nursing care
- Medical social services and dietary counseling
- Medications, medical equipment and supplies used in the facility
- Occupational therapy, physical therapy or speech and language pathology services if needed to meet your health goal
- Ambulance transportation if needed to receive necessary services that arent available in the facility
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Skilled Nursing Facility Stays
Medicare Part A covers Medicare-certified SNF skilled care. Skilled care is nursing or other rehabilitative services, provided according to physician orders, that:
- Require skills of qualified technical or professional health personnel, like registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists
- Are provided directly by, or under general skilled nursing or skilled rehabilitation personnel supervision, to assure patient safety and medically desired results
- General supervision requires initial direction and periodic inspection of the actual activity the supervisor isnt always physically present or at the location when the assistant performs services
We consider a service skilled if its inherent complexity can only be performed safely and or effectively by, or under the general supervision of, skilled nursing or skilled rehabilitation personnel.
Original Medicare enrollees must meet these conditions to qualify for Part A-covered SNF services:
- Patient was a hospital inpatient for a medically necessary stay of at least 3 consecutive calendar days
- Time spent in observation or in an emergency room doesnt count toward a medically necessary 3-day qualifying inpatient hospital stay
- A Medicare Advantage plan, 1876 Cost plan, or Program of All-inclusive Care for the Elderly plan may waive the 3-day stay for enrollees
3-Day Stay Waiver
Stopping Care Or Leaving
If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.
If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesnt need to be for the same condition that you were treated for during your previous stay.
If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
What Is Considered A Skilled Nursing Facility Benefit Period
If youre on Medicare and you need a stay at a hospital or skilled nursing facility , you may hear the words benefit period. Medicare uses this term as a way to measure your use of hospital or skilled nursing facility care. Under Medicare Part A , a benefit period starts on the day youre admitted as an inpatient to a hospital or SNF and ends when youve left and havent received any inpatient care in a hospital or SNF for 60 days in a row.
If youre an inpatient in a hospital or skilled nursing facility again after a benefit period has ended, a new benefit period begins for your second inpatient stay, even if the second stay is related to the first one. For example, lets say you were an inpatient in the hospital for 10 days and then found yourself back in the hospital 70 days after you were dischargeda new benefit period would begin with your second hospital admission.
Conditions for getting Medicare SNF coverageMedicare doesnt pay for long-term care at skilled nursing facilities, as its considered custodial rather than medical. However, if specific conditions are met, Medicare will pay for short-term care at these facilities.
Those conditions are:
- Your benefit period must begin with an inpatient stay at a hospital for at least three days.
- When its time for you to leave the hospital, your physician must order ongoing inpatient care at a Medicare-certified SNF. Typically, you must be admitted to an SNF within 30 days of leaving the hospital.
Where Can I Find Medicare And Medicaid Skilled Nursing Care Near Me
Quick tip: Medicare enrollees can easily search for Medicare-certified providers and facilities through Medicares Find & Compare search tool.
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How Much Do I Pay If Im In A Skilled Nursing Facility
The portion of the costs that you pay depends on the duration of your eligible stay in a skilled nursing facility. Youll have the following copayments for each benefit period:
- $0 for days 1 to 20
- $194.50 a day in 2022 for days 21 to 100
- All costs days 101 and beyond
A Medicare supplemental policy, better known as Medigap retiree coverage or other insurance may cover the copay for days 21 to 100 or add more coverage.
Keep in mind
Medicare doesnt pay for the considerable cost of long-term care in a nursing home or other facility. But you may have other options to help cover long-term care costs.
Private pay. Many individuals and families pay out of pocket or tap assets such as property or investments to pay for long-term care. If they use up those resources, Medicaid may become an option.
Long-term care insurance. Some people buy long-term care insurance that may pay for custodial care in a nursing home or assisted living facility or for a caregiver to come to their home. To qualify for payouts, you generally must need help with at least two activities of daily living or provide evidence of cognitive impairment.
Veterans benefits. Military veterans may have access to long-term care benefits from the U.S. Department of Veterans Affairs .