When MediCARE pays the Nursing Home

 

MediCARE treats long hospital stays as anathema. Acute care, such as that administered in a hospital setting is very expensive. The shorter the hospital stay the better for the insurer. Medicare will only pay for the hospital admission for only as long as acute hospital care is needed to cure and restore the health of the beneficiary. Once the need for acute care ends, Medicare coverage for the hospital admission ends.  MediCARE realizes that a hospital stay does not guarantee a quick cure and a successful immediate return to home. It oftentimes leads to a next lower level of care and a temporary (hopefully) admission to a skilled nursing facility. This temporary stay IS covered by MediCARE if the care to be provided will assist in making you healthy enough to return home. Very often, because many of the same resources (nursing, therapists, physicians, medicines) needed by rehabilitating beneficiaries are also needed by the elderly who are in need of custodial, or long-term care, solutions, the SNIF and the nursing home are oftentimes the very same facility. This is why you will often find Medicare covering the costs of staying in a nursing home/SNIF.

 

Your admission to a SNIF, where restorative and rehabilitative care enable you to get better will be covered by Medicare; but not for unlimited duration.  Medicare covers up to 100 days. This includes medical and nursing services, custodial care, semiprivate room, meals and prescription drugs. (Any drugs you need while receiving the SNF benefit are paid for under Medicare Part A hospital insurance, not under Medicare Part D drug coverage.)

 

This is often one of the most misunderstood Medicare coverage issues that I have ever addressed. The 100 days of coverage is qualified coverage; a physician needs to certify that you qualify for, and will benefit from, using every day of coverage.  It is the unusual case where all 100 days are used. If after your admission to a SNIF, a physician certifies that you can no longer benefit from further skilled care your Medicare coverage ends.  Oftentimes a patient refuses to participate in the therapy offered to restore the patient to health. If the patient refuses therapy, the Medicare insurance coverage ceases. AS LONG AS THE PATIENT IS MAKING PROGRESS, no matter how small (an extra few steps a day without a walker is progress) the coverage continues.

 

Remember, the idea of Medicare’s coverage skilled nursing care is to make you healthier so that you can return home. Once it is determined you will not benefit from the rehabilitative care, or there is a refusal to participate in rehabilitation, coverage ends.

 

BUT, coverage cannot end without the SNIF first providing WRITTEN notice of the end of coverage and the written notice must be provided to the beneficiary no less than 48 hours before the termination date. Thus, the SNIF administrator cannot tell you in a conversation at 10:00 a.m. that you have to leave by 5 p.m.  You should have 2 days to make arrangements for the patient’s discharge.

 

Receipt of Medicare’s written determination that coverage at the SNIF level care is at an end, can be quite the traumatic event for many families, particularly for those families who have planned that the SNIF care would in fact return the patient to a healthy condition and would be able to return home. 

 

If a patient is in bad health and the SNIF coverage ends, and the family is unprepared, the options can be   quite limited.  NO ONE looks forward to the day when placement in a nursing home. But you will hurt yourself and your family emotionally and financially if you do not prepare for this possible outcome.

 

While Medicare covers most of the SNIF costs (and supplemental health insurance pays SNIF costs only for so long as Medicare pays), it days not pay all costs. Here is what MediCARE pays: 

 

Days 1 to 20: You pay nothing. Medicare pays 100 percent of the cost.

Days 21 to 100: You pay a daily copayment—$133.50 a day in 2009—and Medicare pays the rest. (If you have medigap supplementary insurance, long-term care insurance or are in a Medicare Advantage health plan, some or all of this cost may be covered, depending on your policy or plan.)

 

Beyond 100 days: You pay the full costs and Medicare pays nothing. (Long-term care insurance may cover part of the costs OR you may qualify for MediCAID)