does Medicare pay for nursing home

Assisting Your Elders: Does Medicare Pay for Nursing Home Care?

As you grow old and your health deteriorates, the comfort and medical care provided in nursing homes might appeal to you. Unfortunately, paying for them is not easy.

This brings up a commonly asked question:   does Medicare pay for a nursing home? Before answering this question, it is important to look at the Medicare structure and provisions.

We will cover in this article

Medicare covers four parts: A, B, C, and D.

  • Part A, or Original Medicare, covers hospital care, skilled nursing in dedicated facilities, home health, and hospice services.
  • Part B covers medical and clinical laboratory services, preventive and outpatient care, medical screening, surgery costs and supplies, occupational and physical therapy.
  • Part C, or Medicare Advantage, combines the hospital insurance characteristic to Part A with the medical insurance characteristic to part B in one plan that is also compatible with Part D (prescription medicine coverage).
  • Part D covers prescription drugs an can represent a standalone plan or combine with the other three parts in one comprehensive plan.

So, yes, Medicare does cover nursing home care services, but with important limitations that we’ll discuss below.

does Medicare pay for nursing home

When Does Medicare Pay for Nursing Home Assistance?

As shown above, Part A of Medicare covers institutionalized care (hospitalization and nursing home stay), but also certain services provided by home healthcare agencies and hospices.

In order to qualify for such coverage, without having to cover any expenses yourself, you have to be at least 65 years of age, and eligible for Social Security benefits.

You can benefit from up to 100 days of skilled nursing services per illness spell, but the conditions are not easy to meet:

What requirements I need to meet to get 100 Days of Care?

  • You need to enter the nursing home within 30 days from a hospital stay that lasted for at least three
  • The care you receive in the nursing facility should address the condition or disease that made hospitalization necessary, or one directly related to it.
  • The care you receive in the nursing home should not be available for outpatients or as homecare service. It should rely on a physician’s recommendation and be delivered on a daily basis by a medical professional (registered nurse, licensed practical nurse, physical therapist, etc.).
  • The coverage ends when skilled care is no longer necessary. From the 21st day of nursing home care, you become responsible for copayments that equal 1/8 of the daily hospital deductible ($161/day in 2016). Medigap insurance policies usually cover this copayment.

If you are the patient of a skilled nursing facility or hospital and you do not receive skilled care for 60 consecutive days, you will still qualify for Medicare coverage and continued to stay in the skilled nursing facility in the event that you should become ill after the 60-day period.

However, keep in mind that some nursing homes terminate Medicare coverage for skilled nursing earlier than they should, on the assumption that if you stopped making progress, the coverage ends.

In reality, they should continue to provide Medicare-covered skilled care, even if only to help you maintain your health.

Contrary to what some facilities claim, Medicare also covers skilled care that only involves supervision, and no further skilled nursing services.

When you leave the hospital to move into a nursing home, the facility should give you a written notice that confirms your need of skilled nursing care.

If the nursing home staff determines that you no longer need skilled services, they should give you a “Notice of Non-Coverage.” You still have the option of submitting your nursing home bill to Medicare, but your chances to actually have it paid are low.

Final Thoughts about Medicare and Nursing Home Coverage

A company contracted by Medicare will review your bill. You can continue to stay in the nursing home without paying until the verdict of the review arrives.

However, if the verdict is against your interest, you will be responsible for retroactive payments. From this point on, you have several appeal options, but you risk ending up in huge debt accumulated from due retroactive payments.

To sum up, the answer to the question “Does Medicare pay for nursing home services?” is, it might, but only if your health condition makes such services necessary. Otherwise, you might be better off looking into Medicaid assisted living coverage.