For many elders, the first source of payment for medical expenses is Medicare. Medicare Part A pays for inpatient hospital care, and for "extended care" in skilled nursing facilities, as well as hospice care, and home health care.
But Medicare will not pay for any "extended care" in a nursing home, unless the elder was hospitalized for at least 3 days before being admitted to the skilled nursing facility (not counting the day of discharge). Admission to the nursing home must be within 30 days of the hospital discharge.
At some point, you or your family may be confronted by doctors, hospital discharge staff, or nursing home staff, who tell you that continuing long term care won't be paid for by Medicare, or provided by the hospital or nursing home. Our services include showing you how to coordinate your Medicare benefits with other sources of payment for elder care.
Medicare coverage provides payments for skilled care by hospital staffs and physicians. However, Medicare Part A Hospital Insurance will pay for only a limited number of days in a skilled nursing facility (see co payment chart in the side bar on this page).
The Medicare Regulations say the for Medicare to pay for the nursing home days "[t]here must be an expectation that the beneficiary's condition will improve materially in a reasonable (and generally predictable) period of time based on the physician's assessment."
The Regulations also say "[t]he determination of whether skilled nursing care is reasonable and necessary must be based solely upon the beneficiary's unique condition and individual needs, without regard to whether the or injury is acute, chronic, terminal, or expected to last a long time."
Examples: A patient with congestive heart failure may require continuous close observation to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication(s) that serve as indicators for adjusting therapeutic measures. Similarly, surgical patients transferred from a hospital to an SNF while in the complicated, unstabilized postoperative period, for example, after hip prosthesis or cataract surgery, may need continued close skilled monitoring for postoperative complications and adverse reaction. Patients who, in addition to their physical problems, exhibit acute psychological symptoms such as depression, anxiety, or agitation, may also require skilled observation and assessment by technical or professional personnel to ensure their safety or the safety of others, that is, to observe for indications of suicidal or hostile behavior. The need for services of this type must be documented by physicians' orders or nursing or therapy notes.
Your case deserves individual attention, to make sure you receive the full benefits provided by Medicare.