While Medicare does not cover long-term nursing home stays, the federal agency provides limited coveragefor 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?
Does Medicare Pay for Skilled Nursing Care Costs?
Does Medicare pay for nursing home care? To answer that question you’ll first need to know whether you qualify for care and what’s covered under Medicare.
Medicare Part A(hospital insurance) covers skilled nursing home care on a short-term basis as long as you meet certain eligibility criteria. According to Medicare.gov, to qualify for Medicare Part A coverage, you must meet the following requirements:
— You have Part A and also have time left in your benefit period.
— 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 enter the facility within 30 days of leaving the hospital.
— 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.
— You need skilled nursing care or therapy to maintain or improve your condition or to prevent or delay the condition getting worse.
— Your care is in a Medicare-certified skilled nursing care facility.
[Read: Medicare Fall Open Enrollment: What You Need to Know.]
How Long Does Medicare Pay for Skilled Nursing Home Care?
If you meet these requirements, the length of time Medicare will pay for a skilled nursing home stay depends on several factors, including your progress and whether you continue to require daily care or therapy services that can be provided only in a skilled nursing home facility.
Medicare will cover up to 100 days of skilled nursing care in a benefit period. A benefit period starts the day you’re admitted to a hospital or skilled nursing facility as an inpatient and ends after you’ve gone 60 consecutive days without receiving hospital inpatient care or after receiving care for up to 100 days in a skilled nursing facility. If you’re admitted again after a benefit period ends, a new one begins, and you’ll need to pay the deductible. There’s no limit to how many benefit periods you can have.
Medicare Advantage plans must offer the same coverage, but some may have specific networks of skilled nursing facilities that you’ll need to use to take full advantage of your benefits. Additionally, some plans may have different rules or requirements for accessing care. Check with your plan to confirm your specific benefits and requirements.
[Read: 5 Steps for Picking a Medicare Plan.]
What Medicare Pays For
Medicare pays for the skilled nursing or skilled therapy to treat and manage your condition. It covers the following services in a skilled nursing facility:
— Ambulance transportation
— A semi-private room
— Dietary counseling
— Meals
— Medical supplies and equipment
— Medical social services, including counseling
— Occupational therapy
— Physical therapy
— Skilled nursing care
What patients pay
How much a patient pays for care at a skilled nursing facility depends on the length of time of their stay.
— First 20 days.Patients pay $0 after the deductible, though some Medicare Advantage plans charge a copayment during the first 20 days. Check with your plan for more information.
— Day 21 to 100.Up to $204 per day, depending on how the patient is progressing and what their care needs are over time.
— After day 100. 100% of the cost of care.
Your doctor or healthcare provider may suggest services more frequently than Medicare covers or treatments that Medicare doesn’t pay for. In such cases, you might be responsible for some or all of those costs. Be sure to ask questions to understand why certain services are recommended and how much Medicare will contribute.
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
— Nonprofit care
— 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 $240 for 2024, you’ll pay 20% of the Medicare-approved amount for the service. Your total amount will also depend on whether or not you have other insurance like a Medicare Advantage plan or a Medigap supplemental 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 on a part-time or occasional basis. Medicare does not cover 24-hour care at home.
— 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.
As with other types of insurance, you typically pay monthly premiums.
Medicaid coverage
Medicaidis the joint federal-state insurance program that offers health coverage to eligible low-income individuals. Medicaid eligibility has typically been limited to low-income children, pregnant women, parents of dependent children, elderly individuals and individuals with disabilities.
Medicaid eligibility is based on your modified adjusted gross income, according to Medicaid.gov. Many people assume they aren’t eligible for Medicaid because of their income and assets, but a Medicaid “spend down,” which involves reducing your finances to meet the program’s eligibility requirements, may help you qualify.
Keep in mind however that Medicaid does a five-year look back of your assets and reviews all financial transactions during that period. “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,” warns Nevins. Consult with an elder law attorney or financial planner to see what your options are.
Nonprofit care
There are several nonprofit 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 nonprofit, outpatient 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 aid.
Private pay
You can choose to pay for at-home care or skilled nursing care out of pocketif you have the financial means to do so.
However, costs can be high for this type of care, so this option may not be sustainable for extended periods. Annually, the national average for a semi-private room in a nursing home facility is approximately $104,000, while a private room can run around $116,000, according to Genworth Financial’s Cost of Care Survey.
Appeals Process for Medicare Coverage
If you do not believe your care should end at a skilled nursing facility and you still meet the qualifications, you have the right to appeal. Follow these steps to appeal your coverage with Medicare. Information about the Medicare appeals process is availableonline.
Step 1: Getting started with a Medicare appeal
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 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 care, 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. If the appeal is successful, you’ll continue receiving Medicare-covered care as long as your doctor certifies that it’s needed.
Step 2: 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 to handle 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.
Step 3: Escalating the appeal
If your appeal is denied by the QIC and your care is valued at least $180 in 2024, 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’s 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 theOMHA online portal. A successful appeal at the OMHA level secures ongoing Medicare-covered care, contingent upon your doctor’s certification.
Step 4: 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 $1,840 in 2024, 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 you will require support from a qualified lawyer.
Bottom Line
Medicare covers short-term skilled nursing care in a Medicare-certified facility for up to 100 days in a benefit period. It’s important to understand what Part A or your Medicare Advantage plan covers and the costs before admission to a skilled nursing facility.
“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 questionsregarding Medicare coverage and get you the help you need.”
If you require ongoing care after your Medicare Part A coverage for a skilled nursing stay ends, depending on your situation there are several options available to you, such as at-home care, Medicaid, nonprofit care, activating long-term care insurance and paying out of pocket. If you feel you are being discharged prematurely and still meet the requirements for care, you have several levels of appeal available to pursue.
It’s important to understand your benefits, costs and rights before entering a skilled nursing facility to avoid unexpected expenses and ensure you receive the care you’re entitled to.
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When Medicare Stops Paying for Nursing Homes originally appeared on usnews.com
Update 10/17/24: This story was previously published at an earlier date and has been updated with new information.
