Medicare Questions by Kate Sullivan Nowadly

Will My Rehabilitation Stay at the Nursing Home by Covered By Medicare?

For People with Original Medicare:

Many people find themselves temporarily in a skilled nursing facility for rehabilitation after a going to the hospital- an accident or fall, or perhaps a stroke or a heart attack can cause them to need rehabilitation for a period of time. Most people go to these places to receive care for a short period of time and do not think or worry about how this skilled care will be paid for later. Medicare will cover this temporary care in a skilled nursing facility if certain conditions are met. If they are not- you or someone you care for could be responsible for a sizable bill after their stay.

When Will Medicaid Cover Care in a Nursing Home (AKA a “skilled nursing facility”)?

Medicare should cover your care if you meet the following criteria:

1)      You have Medicare Part A

2)      You must have a Qualifying Hospital Stay : This is usually the problem area!

  1. You must have an inpatient hospital stay of three or more consecutive stays in a hospital. The count starts when you are admitted into the hospital, but does not include the day of discharge.
  2. The time spent being observed at the hospital before being admitted does not count toward the three day stay
  3. What is an “inpatient” hospital stay?

i.      A doctor makes an official order which says you need 2 or more midnights of medically necessary inpatient hospital care to treat your illness or injury and the hospital formally admits you.

ii.      You need the kind of care that can be given only in a hospital.

iii.      The hospital accepts Medicare.

iv.      The Utilization Review Committee of the hospital approves your stay while you’re in the hospital.

  1. ALWAYS ASK: Am I being officially admitted to the hospital right now? Am I am inpatient? WHEN and HOW you are admitted are very important! Do not be afraid to ask for copies of all Admissions paperwork.

3)      You must enter the Skilled Nursing Facility a short period of time after leaving the hospital (within 30 days).

 

4)      Your doctor ordered services you need for Skilled Nursing care

  1. Must require the skills of professional personnel such as: nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists.
  2. The care must be given by, or under the supervision of, these skilled personnel.

 

5)      You require skilled care on a daily basis and the services must be the kind that can only be provided in a skilled nursing facility (nursing home). If you are just getting rehab- you must get it 5 or 6 days a week to qualify.

6)      Must need the skills and services for a medical condition that was:

  1. Treated during the 3-day Qualifying Stay in the hospital OR
  2. Started while you were getting care in the Skilled Nursing Facility for a medical condition that was treated during a 3-day Qualifying Stay in a hospital (for example, you enter for rehab on a dislocated hip but have a stroke while at the rehabilitation facility. You might not need rehab on the hip anymore, but now need rehab for the stroke).

7)      The skilled services you are receiving must be reasonable and necessary for the diagnosis or treatment of the condition.

8)      The facility must be certified by Medicare to provide your care.

I meet all the criteria. How long will Medicare cover my stay in the Nursing Home?

Medicare will pay the full cost of covered services for the first twenty days and then all but the daily copayment (up to $152/day) for the next 80 days. After 100 days, Medicare will no longer cover your case in the nursing home.

REMEMBER: Medicare will only continue to pay for any of your care if you are receiving skilled nursing services that are reasonable and medically necessary.

IF THE NURSING HOME ISSUES YOU A NOTICE STATING THAT MEDICARE WILL NO LONGER COVER YOUR STAY- You should reach out to an attorney or a local civil legal services agency for help in fighting that decision.

 

IMPORTANT NOTE ABOUT MEDICARE COVERAGE:

Medicare uses a period of time called a benefit period to keep track of how many days of Skilled Nursing benefits you use, and how many are still available to you.

A benefit period begins on the day you start using hospital or Skilled Nursing Facility benefits under Part A of Medicare. You can get up to 100 days of coverage in a benefit period. Once you use those 100 days, your current benefit period must end before you can renew your SNF benefits.

How does my benefit period end?

1)      When you have not been in a nursing facility or a hospital for at least 60 days in a row, OR

2)      If you stay in a Skilled Nursing Facility but you haven’t received skilled care there for at least 60 days in a row.

There is no limit to the number of benefit periods you can have.

Once a benefit period ends, you must have another 3-day qualifying hospital stay and meet the listed Medicare requirements.

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