Medicare coverage for nursing home care

If a patient has spent 3 days in the hospital, Medicare may pay for care in a Skilled Nursing Facility:
imageDays 1 – 20: $0 co pay for each benefit period
Days 21 - 100: patient pays $157.50 coinsurance per day during 2015
image Days 101 and beyond: patient pays all costs

Do you know your rights to nursing home coverage under Medicare? Medicare Part A pays for inpatient hospital care, and then for care in a skilled nursing facility IF the patient has a "qualified" hospital stay of at least 3 days (not counting day of discharge) before being admitted to the skilled nursing facility. Admission to the nursing home must be within 30 days of the hospital discharge. But patients put on Hospital Observation Status end up paying out-of-pocket if they need nursing home care:


PDF Summary. Medicare is telling hospitals to keep patients "under observation," to prevent eligibility for the 100 days of Skilled Nursing Facility benefits. A Medicare fact sheet warns patients to ask about their status when they are in the hospital: "You’re an inpatient starting the day you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day."

US CapitolCongress has voted to require hospitals to tell Medicare patients when they are under observation care and have not been admitted to the hospital. When signed by the President, the law will require hospitals to provide written notification to patients 24 hours after receivinMassachusetts mapg observation care, explaining that they have not been admitted to the hospital, the reasons why, and the potential financial implications. Hospitals will have 12 months to begin complying with the patient notice requirements.

In Massachusetts House bill H 2029 is scheduled for a public hearing on December 8, 2015. After that, the Public Health Committee has until March 16, 2016 to vote the bill out of Committee. Then the bill has to go through various other Committees and pass before the end of December 2016, before it would require hospitals in Massachusetts to give notice of observation status to patients.

twin hurdles

If you go to the nursing home after a qualified hospital stay, there may be a second hurdle. Nursing homes are often reluctant to keep billing Medicare, because they think Medicare coverage depends on beneficiary’s restoration potential; but the standard is whether skilled care is required:

PDF Summary. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. The nursing home patient who needs these skilled services should still be covered by Medicare articleHospital Observation Status can be financially devastating. Read More by Attorney John L. Roberts at: "This happened to us last year. After 4 days we were told the status was changing to outpatient." More in Reader Comments.

Getting Medicare to pay for skilled nursing home care.
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