If you or a loved one is in need of skilled nursing care, you may be wondering about Medicare skilled nursing coverage. Learn more about what is covered here.
Being ill is no fun at all, and receiving an unexpected bill makes the situation all the more stressful.
Unfortunately, it’s an experience many elderly face. Individuals age 65 and up are three times as likely to go to the hospital than those between 45 and 65, and they are also the ones usually relying on Medicare to pay their bills.
When the discussion turns to Medicare skilled nursing, things become even more jumbled for the patients and for their decision makers.
It’s time to sort it all out. Here, we’ve broken down the rules so that you know what to expect when you need skilled nursing care.
What Is Medicare Skilled Nursing?
Skilled nursing care is comprised of 24-hour medical care provided by professionals or specialists in the field. In order for the care to be safe and effective, medical personnel must be in attendance.
Skilled nursing care can involve something as simple as a shot or something as rigorous as physical therapy.
The most common reasons for hospitalization in adults over the age of 65 include infections and cardiovascular complications. However, other common reasons for admission that require skilled nursing include:
- Rehabilitation therapy after a stroke
- Post-operation wound care and dressing changes
- Tube feeding and Tracheostomy Care
- Monitoring a rapidly-changing health status, such as a serious illness
Is Hospice Skilled Nursing?
While these descriptions probably sound like what you’d expect in a nursing home, skilled nursing differs considerably from hospice and long-term care.
Think of skilled nursing as that happy in-between; patients usually can’t go in and out of the doctor’s office in an hour, but they also don’t require ongoing care for several months or years.
Requirements for Coverage
Many Medicare recipients get a nasty surprise when, at the end of their stay, they are expected to foot a hefty fine.
Unfortunately, Medicare’s coverage depends largely on several factors. Generally, Medicare pays for an individual’s care if beneficiaries meet all these criteria:
- The individual has Medicare Part A
- There are days left in their benefit period
- The beneficiary stays at the hospital for three consecutive inpatient days or more (outpatient services are not counted towards the total days)
- The doctor requires that the individual have daily, skilled care
- Care is provided by licensed and/or registered medical personnel
- The facility is Medicare-certified
- The services are required for the beneficiary’s condition
What Does Medicare Cover?
Medicare will pay for all or part of your loved one’s health services depending on the situation. Generally, however, there are a few things you can expect to be covered.
Items and Services
Medicare covers a broad range of useful and needed items and/or services. Several of these necessities include:
- Dietary counseling
- Shared rooms
- Physical therapy
- Care by medical staff
- Use of medical supplies and equipment
If you or your loved one is an inpatient for up to 20 days, Medicare will pay 100% of the costs.
If the individual remains in skilled nursing care for 21 to 100 days, patients pay the daily coinsurance. While coinsurance rates change, the daily amount in 2019 is $170.50 (for Medicare Part A beneficiaries).
To view the various costs in 2019 for Medicare beneficiaries, CMS.gov has a fantastic fact sheet that breaks it down.
What Isn’t Covered?
As with any program, Medicare’s skilled-nursing care benefits has limits.
Stays Over 100 Days
If a patient remains in the skilled nursing facility (SNF) for over 100 days, Medicare will not pay for any of the costs after the one-hundredth day.
That means the patient and his or her family must pay for all medical costs after this point.
Care from medical facilities that are not Medicare-licensed and/or approved is not paid for by the program. Always check carefully for licensed facilities in your area.
It is also a good idea to check that the hospital is in your Medicare network or to speak to a Medicare representative to ensure you have a list of accepted facilities.
Other Types of Care
Medicare does not pay for long-term care, commonly referred to as nursing home care. It also does not cover hospice care or palliative care, which specializes in providing relief from chronic illnesses and symptoms.
If any of these care types are needed, speak to your doctor to request additional information.
Understanding Medicare SNF benefits seems like a daunting task, but if decision makers and beneficiaries adequately prepare themselves, it is much easier to handle.
Frequently, Medicare beneficiaries find they need care for a day or two, return home and require care again several days later.
In these instances, individuals who return to the facility for the same or a related condition within 30 days do not need to restart the three-day inpatient stay criterion. However, if the period without care extends into the next beneficiary period, the three-day stay is required.
Before any emergencies occur, it’s best to know what facilities you or your loved one would be comfortable staying at. Ask for a tour of nearby facilities and make a list of all locations the beneficiary feels comfortable at.
Don’t forget to research the SNF and to check it is Medicare-licensed.
If an accident occurs or the beneficiary uses his or her skilled nursing benefits, it’s vital to keep close records of events.
Request that the staff members give detailed reasons for all inpatient and outpatient services. Make sure the reasons are provided in writing; this will act as proof that the services were required.
Also, keep track of the days in a benefit period. Without understanding when one period starts and ends, comprehending whether an inpatient day “counts” becomes complicated.
Finally, keep in mind that further coverage is available. Medigap provides additional coverage for people who use original Medicare. However, it does require an additional premium.
Medicare Advantage Health Plans work similarly to private insurance companies. They also cover additional services, such as lab work or doctor visits, and individuals provide a co-pay.
Services like these, while additional costs, offer extended skilled nursing services not covered by regular Medicare.
Brighten the Day
Understanding Medicare skilled nursing benefits makes life a lot easier when your loved one is admitted, and having a skilled nursing facility like MediLodge is one simple way to take the worry off your and your loved one’s shoulders.
But it’s not the only way to relieve the stress that illness creates.
Brighten up your parent’s, friends, grandparent’s or dear one’s day by sending a personalized e-card. Our staff members are happy to print your card and personally deliver it to them.
We would love your help in bringing smiles to every patient’s face.