While Medicare does not cover long-term nursing home stays, the federal agency provides limited coverage for short-term support in skilled nursing care facilities.
These facilities specialize in providing short-term care and rehabilitation for people who are recovering from illness, injury or surgery and may need physical, occupational and rehabilitative therapy after their hospital release.
However, there’s no blank check from Medicarewhen someone enters skilled nursing care facilities.
So, what happens when Medicare coverage for skilled nursing care ends?
[READ: How Do You Apply for Medicare?]
Does Medicare Pay for Skilled Nursing Care Costs?
First, it’s important to know whether you qualify and what’s covered under Medicare.
Medicare Part A (hospital insurance) covers skilled nursing care as long as you meet certain eligibility criteria. To qualify for Medicare part A coverage, you must meet the following requirements:
— You’ve had a hospital stay of at least three days (not including the day you leave the hospital).
— Your doctor determines you need daily skilled nursing care.
— You need skilled nursing services for a hospital-related medical condition (like an infection) that you were treated for during your qualifying three-day inpatient hospital stay, even if it wasn’t the reason you were admitted.
What Medicare pays for
People can get 100% of the costs covered by Medicare for the first 20 days at a skilled nursing care facility.
Medicare covers the following services in a skilled nursing facility:
— A semi-private room.
— Meals.
— Dietary counseling.
— Skilled nursing care.
— Occupational therapy.
— Medications.
— Medical supplies and equipment.
— Medical social services, including counseling.
— Ambulance transportation.
What patients pay
How much a patient pays for care at a skilled nursing facility depends on the length of time they are there for.
— First 20 days: Patients pay $0.
— Day 21 to 100: Up to $200 per day (in 2023), depending on how the patient is progressing and what their care needs are over time.
— After day 100: 100% of the costs of care.
[READ: Medicare Mistakes to Avoid.]
What Can You Do When Medicare Stops Paying?
If you need continued care after your Medicare Part A coverage for a rehabilitative skilled nursing stay ends, you have various options, including:
— At-home care.
— Long-term care insurance.
— Medicaid.
— Non-profit care.
— Private pay.
— Appeals.
At-home care
Many people who leave a skilled nursing care facility after a few weeks will need continuation of services at home or at another facility.
“For many, returning home and receiving at-home care is a good option because Medicare will cover several home health therapies and services,” says Karen Doyle, associate executive director at Goodwin House Bailey’s Crossroads, a Goodwin Living Life Plan Community, in Falls Church, Virginia.
After you pay the Medicare Part B (medical coverage) deductible, which is $226 for 2023, you’ll pay 20% of the Medicare-approved amount for the service. The amount an individual will pay depends on a variety of factors, such as whether the person has other insurance like a Medicare Advantage plan.
“There are limitations to what Medicare will pay for, so it’s important to talk to them about what they cover and don’t cover,” says Erin Nevins, president of USA Medicare Consultants, a division of EP Nevins Insurance Agency Inc., of Greenville, New York.
Here’s what Medicare Part B will typically cover at home:
— Therapy: Medicare covers physical, occupational and speech therapy if they are considered reasonable and necessary to treat your condition. A qualified therapist must prescribe and oversee these services.
— Home health aide services: If you are receiving skilled nursing care, Medicare may cover some home health aide services, like help with bathing, dressing, and toileting. These services are usually provided on a part-time or occasional basis. Medicare does not cover 24-hour-a-day care at home, meal delivery, cleaning and shopping services and personal care provided by home health aides.
— Social services: Medicare may cover medical social services to help you with social and emotional concerns related to your illness. This may involve counseling, well-being support or help finding resources in your community.
— Durable medical equipment: Medicare covers certain medical equipment like wheelchairs, walkers and hospital beds that your doctor prescribes for use in your home.
Long-term care insurance
If you planned ahead and took out a long-term care insurance policy, it may cover some of the costs of skilled nursing care after your Medicare benefit stops.
Coverage will vary depending on the policy, says Jay Zigmont, founder of Childfree Wealth, which provides life and financial planning services. Long-term care insurance is private insurance that helps people cover the costs of long-term care for a chronic illness or other serious condition, like the effects of a stroke, in a facility like a nursing home.
Like other types of insurance, you typically purchase it by paying monthly premiums.
Medicaid
Medicaid is the joint federal-state insurance program that offers health coverage to eligible low-income individuals. Medicaid eligibility has been usually limited to low-income children, pregnant women, parents of dependent children, elderly individuals and individuals with disabilities.
To be eligible for Medicaid, one cannot have annual income greater than $14,580 for individuals and $19,720 for a couple.
“Medicaid does a five-year look back of your assets and reviews all financial transactions during that period,” Nevins warns. “Putting your house in your spouse’s name or children’s names will disqualify you from receiving Medicaid support if it’s within the past five years.”
Non-profit care
There are several non-profit physical and rehabilitation services available for qualifying individuals. For instance, NeuroHope was founded in 2013 in Indianapolis to offer physical rehabilitation to make long-term, post-hospital care an affordable reality for survivors of spinal cord injury, brain injury and stroke when insurance caps or Medicare stops payment.
Neuroworx, based in Salt Lake City, is a non-profit, out-patient facility providing therapy to adults and children affected by neurological conditions.
In addition, disease-specific foundations focused on stroke, Parkinson’s disease, epilepsy and other chronic conditions sometimes offer financial assistance to cover certain expenses.
Look for national and local groups dedicated to your chronic condition that may offer help.
Private pay
You can choose to pay for at-home care, skilled nursing care out of pocket if you have the financial means to do so.
However, costs are high for this type of care, so this option may not be sustainable for a long period of time. For assisted living and memory care, monthly fees range from $8,200 to $11,000 a month. For skilled nursing care, the price is about $17,000 a month.
Appeals
If you do not believe your care should end at a skilled nursing facility yet even though you still meet the qualifications, you have the right to an appeal.
[READ: How to Find and Choose an Assisted Living Community: A Checklist]
Appeals Process for Medicare Coverage
Follow these steps to appeal your coverage with Medicare. Information about the Medicare appeals process is available online.
First steps
If you think your care should continue, adhere to the instructions on the Notice of Medicare Non-Coverage to file an expedited appeal with the Quality Improvement Organization (QIO) by noon on the day before your care is due to end. In the case of home health care, the notice should be given during your second-to-last care visit.
QIOs are a group of doctors and health care experts who address complaints in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. The QIO must make a decision no later than two days after your scheduled end of care.
Typically, the QIO will contact you for your input. Alternatively, you can submit a written statement. If you receive home health, you need a written statement from a physician confirming the necessity of continued care.
If you miss the expedited QIO review deadline, you have up to 60 days to file a standard appeal with the QIO, provided you are still receiving care. The QIO should make a decision as promptly as possible after receiving your request. If you are no longer receiving care, the QIO must decide within 30 days. A successful QIO appeal ensures your continued receipt of Medicare-covered care, pending your doctor’s certification.
Next steps after denial
If the appeal is denied, don’t give up. The next step is appealing to the Qualified Independent Contractor (QIC) by noon on the day following the QIO’s decision.
The QIC is an independent group that Medicare contracts with to handle the appeals. QIC should decide within 72 hours. However, if your appeal is unsuccessful, you are responsible for all costs, including those incurred during the 72-hour deliberation period.
If you miss the QIC deadline, you have up to 180 days to file a standard appeal with the QIC. The QIC should decide within 60 days.
“A successful appeal to the QIC ensures continued receipt of Medicare-covered care, subject to your doctor’s certification,” Nevins says.
Escalating the appeal
If your appeal is denied by the QIC and your care is valued at least $180 in 2023, you can appeal to the Office of Medicare Hearings and Appeals (OMHA) within 60 days of the QIC denial letter date.
OMHA provides an opportunity for individuals and organizations who are dissatisfied with Medicare initial decisions or eligibility to have a hearing in front of an Administrative Law Judge. While legal assistance is optional, it might be beneficial. OMHA should decide within 90 days.
An appeal can be filed electronically at the OMHA online portal. A successful appeal at the OMHA level secures ongoing Medicare-covered care, contingent upon your doctor’s certification.
Final opportunity
If your appeal is denied, you can escalate by appealing to the Medicare Appeals Council within 60 days of the OMHA denial letter date.
A successful appeal to the council guarantees continued Medicare-covered care, as long as your doctor certifies it.
If your appeal is denied and your care’s value is at least $1,850 in 2023, you can appeal to the Federal District Court within 60 days of the Council denial letter date. The Federal District Court does not have a specified timeframe for making a decision and will require support from a qualified lawyer.
Bottom Line
It’s important to review your plan and know your rights about what Medicare will pay for when skilled nursing care is needed. Specific services and the amount of coverage can vary based on your individual circumstances, and Medicare rules can change over time, but there are options.
“It’s worthwhile to contact Medicare or visit its website for the latest and most detailed information regarding covered care,” Nevins says. “During a hospital visit, the hospital staff will often help answer questions regarding Medicare coverage and get you the help you need.”
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What to Do When Medicare Stops Paying for Skilled Nursing Care originally appeared on usnews.com
Update 10/10/23: The story was previously published at an earlier date and has been updated with new information.
