Medicare Payments for Nursing Home Care
Protecting Benefits and Coverage
Do you know your rights to nursing home coverage under Medicare? Medicare Part A pays for inpatient hospital care, and for "extended care" in skilled nursing facilities, Medicare will pay for skilled care in a nursing home IF the elder was hospitalized for 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.
Last year, Medicare began directing hospitals to keep patients "under observation," to prevent eligibility for the 100 days of Skilled Nursing Facility benefits available to those who enter a nursing home after a hospital stay of 3 or more days. The Center for Medicare Advocacy has filed suit on behalf of seven people from Connecticut, Massachusetts, and Texas who were denied Medicare benefits because of hospital "observation status."
When the person has spent 3 days in the hospital, Medicare must pay for a limited number of days in a Skilled Nursing Facility.
Days 1 - 20: No Co-Pay. Medicare pays all costs.
Days 21 - 100: Co-pay of $148.00 per day.
You may be confronted by hospital or nursing home staff, who tell you that Medicare will not continue to pay for care. They may refer you to Medicare Regulations that say the patient's condition must be expected to improve in a reasonable and predictable period of time based on the physician's assessment. If the patient has reached what the hospital or nursing home staff people think is maximum improvement, they decide to tell family members that Medicare will no longer pay the bill.
But there are many Medicare Regulations that protect your rights to continued coverage if you need skilled care. Medicare regulations say "the 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 injury is acute, chronic, terminal, or expected to last a long time." Call us if you need to protect these important rights to health care services that Medicare does cover.