The thought of a nursing home can be scary. Not only having to go there but wondering how you are going to pay for it. Many people begin to question if or how long Medicare will pay for a nursing home stay? While Medicare isn't designed for nursing home stays, it can be covered if you meet a few different requirements.
How Long Will Medicare Pay for a Nursing Home Stay?
Medicare is a health insurance program available to Social Security recipients who are 65-years-old or older, people who are disabled, those experiencing stage four renal failure, or people who have received Social Security Disability Benefits for the previous 25 months or longer. Medicare should not be confused with Medicaid, which is a State and Federal program available for people who have limited income and assets.
In order to be eligible for nursing home care with all or some services paid for by Medicare, first a person must qualify to receive the benefits. Qualification includes a hospital stay of at least three days under the care of a Medicare-certified nursing staff. This hospital stay must take place 30 days prior (or less) before moving to the nursing home. Secondly, the nursing home you choose must be Medicare and Medicaid-certified for Medicare to pay. To find a Medicare and Medicaid-certified facility visit Medicare.gov.
For those wondering, "How long will Medicare pay for a nursing home stay?" the truth is that, typically, Medicare doesn't pay for long-term care. It is designed to help cover the costs for skilled nursing care needed following a hospital stay and coverage includes up to 100 days of services per illness. "Skilled care" in this sense means nursing or rehabilitation services performed by professionals who are able to manage and evaluate the patient's care and needs. Long-term stays in nursing homes fall under a different category and are not included in Medicare plans.
Nursing Home Care Eligible for Medicare
The main points to be aware of are that to be eligible for a nursing home stay covered by Medicare, the following requirements must be met:
- The nursing home must be Medicare approved
- Medicare participant must enter the nursing home within 30 days of a hospital stay of three days or longer.
- Medicare participant must require skilled care.
- Required treatment must be ordered by a physician and performed by an LPN, RN or physical therapist.
- In general, Medicare covers acute care, but it does not pay for services needed to help with everyday activities like getting dressed or bathing.
Coverage in the Nursing Home
Once a Medicare participant is enrolled in a Medicare-approved facility, Medicare covers the following costs for 20 days:
- Semi-private room
- Skilled nursing and rehabilitative services
- Necessary medical supplies
After the first 20 days, Medicare participants will be responsible for a daily copay amount of $137.50 (2010) for the remaining 80 days of the 100 day stay. After day 100, the Medicare participant is responsible for 100% of costs. If Medicare is no longer paying and the patient cannot afford to pay, the nursing home will issue a written notice of non-coverage. Once the notice is issued, the nursing home can discharge the patient the following day.
Notice of Non-coverage and Appeals
The notice of non-coverage should include an explanation of how to file an expedited appeal to QIO (Quality Improvement Organization). The sooner the appeal is made, the better. While the appeal is being considered, care continues at no cost, but if the QIO denies coverage, the Medicare participant will be responsible for costs incurred in the interim. If the QIO denies coverage, a further legal step would be to appeal to an Administrative Law Judge with the help of a lawyer.
These requirements that patients must meet in order for Medicare to cover nursing home stays are fairly stringent, and the most important thing to remember is that even if these requirements are met, Medicare will only pay for a limited period of time. For this reason, it is important to consider other alternatives for payment long before nursing home care may be required.