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Nursing Homes and Medicare

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If you or a loved one cannot live at home independently, a nursing home may be the best possible option. Medicare generally does not pay for long-term nursing home care, but covers short-term care while you recover from an illness or injury.

Nursing homes are not the same as assisted living or independent living facilities. Independent living facilities are usually apartments or homes for seniors who need little or no help or care. Assisted living facilities offer a level of care that's between independent living and skilled nursing. Assisted living usually does not include medical care. Medicare generally does not cover care at assisted or independent living facilities.

Advantages of a nursing home

Even if you live with loved ones, they might not be able to provide the level of care you need. Whether you need medical help (for example, you have a feeding tube) or custodial help (for example, help bathing), it can be demanding for loved ones to give this constant care and to do it right.

  • Nursing homes have trained staff; most have skilled nurses and nurses' aides available 24/7. Often a doctor is on the staff or makes frequent visits to the home.
  • Nursing homes have government oversight; the Centers for Medicare & Medicaid Services (CMS) contracts with every state to inspect all nursing homes that participate in Medicare or Medicaid.
  • Some nursing homes function like hospitals, with nurses' stations on each floor, and they provide physical, speech, and occupational therapy, in addition to medical care.
  • Other nursing homes feel more like your own personal home--residents may have open kitchens and interact with neighbors, and the staff is encouraged to develop relationships with residents.
  • Many nursing homes have special care units for people with serious memory problems, such as Alzheimer's disease.
  • Some homes will let couples live together.
  • Nursing homes are for anyone who requires 24-hour care and not just for the elderly.

What kind of care do nursing homes provide?

Nursing homes give care in both of these general areas:

  • Custodial care is help with daily activities such as dressing, eating, and bathing.
  • Skilled nursing care is given by a nurse or rehabilitation specialist to manage, observe, and evaluate your care. It can include medication management, wound care, dialysis, and more (depending on the facility).

Nursing homes are not just for eldercare. They can also provide:

  • Rehabilitation services -- the goal of this kind of care is to help your condition improve so that you can eventually live on your own. For example, if you have major surgery and are released from the hospital, your doctor might order rehabilitation services for you until you recover enough to live independently at home.
  • Long-term care for a serious illness, such as multiple sclerosis (MS).

Eligibility for Medicare skilled nursing coverage

In general, Medicare covers short-term skilled nursing care, with many limitations.

You may qualify for Medicare coverage if you meet these requirements:

  • You have Medicare Part A (hospital insurance).
  • You have an inpatient stay of at least three days in a row (a "qualifying stay"), counting the day of inpatient admission to the hospital, but not counting the day of discharge, before being admitted to the nursing home.
  • Your nursing home is certified by Medicare.
  • You start your stay at the nursing home within a short time (generally, 30 days) after discharge from the qualifying three-day hospital stay.
  • Your doctor has ordered nursing home care and services for you.
  • You need these services on a daily basis (see Exception below).
  • The services are provided or supervised by skilled professionals.
  • You need these services for either of the following:
    • a hospital-related condition that was treated during the qualifying three-day hospital stay, or
    • a condition that arose in the nursing home while you were being treated there for a hospital-related condition

Exception: If you are in a nursing home for rehabilitation services and not for skilled nursing care, the "daily basis" requirement is more flexible. For example, if you are getting therapy (such as occupational therapy) only a few times per week, Medicare counts it as daily care if you have the therapy every time it's offered to you. If you refuse the therapy, Medicare might not cover your stay in the facility.

Covered nursing home services

If you meet the requirements listed above, Medicare Part A coverage includes, but is not limited to:

  • A semi-private (shared) room
  • Meals
  • Skilled nursing care
  • Physical, occupational, and speech therapy
  • Medical social

    services

  • Certain prescription drugs
  • Medical supplies and equipment used in the facility
  • Ambulance transportation to needed services, in some situations
  • Nutrition therapy (usually for beneficiaries with kidney disease)

What Medicare doesn't cover

Here are some examples of nursing home services that Original Medicare (Part A and Part B) doesn't pay for in most situations:

  • A private room
  • Custodial care (such as help dressing or bathing), if it is the only kind of care you need
  • Services given at a facility that isn't Medicare-approved

Your nursing home costs in 2015:

  • Medicare pays 100% of the first 20 days of a covered nursing home stay.
  • Days 21 to 100: $157.50 coinsurance per day of each benefit period. You pay coinsurance for each day of the benefit period.
  • If you stay in a skilled nursing facility longer than 100 days per benefit period, Medicare stops paying nursing home costs. (A benefit period ends when you haven’t received any inpatient hospital care, including nursing home care, for 60 days in a row.)

Other nursing home coverage

If you qualify, due to medical necessity, you may have other options available to you for Medicare coverage of nursing home care:

  • Some Medigap (Medicare Supplemental Insurance) plans help pay for nursing homes. If the care and services you get are covered by Medicare, usually there are still at least some costs to you. If you have a Medigap plan, it might pay for some of those costs.
  • Certain nursing homes have contracts with Medicare plans, such as Medicare Advantage plans (Medicare Part C). In such cases, the plan might help pay for the nursing home care. If you have a Medicare Advantage plan or a Medicare Supplement Plan, ask your plan provider about their nursing home coverage.
  • If you have a Medicare Part D prescription drug plan, it covers drugs that skilled nursing staff gives you.
    • If you're enrolled in both Medicare and Medicaid, Medicare enrolls you into a Medicare Part D prescription drug plan automatically.
    • If you're not eligible for Medicaid, you might have to pay for some or all of your drug costs.
  • Some employer group health plans and long-term care insurance help cover the costs of nursing homes.
  • If you're eligible for Medicaid, it might pay most of your nursing home costs. Your state's State Health Insurance Counseling and Assistance Program (SHIP) program can tell you if you qualify. You can call 1-800-MEDICARE and ask a Medicare Ombudsman about the SHIP program.

Tips on choosing a nursing home

The information contained in this article is for informational purposes only. It should never be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition.

Whether you are moving to a skilled nursing facility yourself, or looking for a facility for a loved one, choosing a nursing home is a big decision.

  • Your hospital's discharge planner or social worker can tell you about Medicare-approved nursing homes in your area.
  • Medicare.gov has a Nursing Home Compare page on its website. You can type in your city or zip code, and it displays a list of local Medicare-approved facilities.
  • Ask the facility all the important questions for you, including if they will hold a bed for you, and how much that would cost.

Nursing home appeals

Medicare coverage of nursing homes is based on each specific case and depends on the beneficiary's needs and abilities. You can file an appeal if you believe there is a problem with your Medicare coverage; for example, if Medicare (or any Medicare health plan, such as Medicare Part C or Part D):

  • Denies your request for an item or service that you think you're entitled to.
  • Won't pay for an item or service that you think you're entitled to.
  • Denies your request to change how much you pay for an item or service.
  • Stops providing, or paying for, an item or service you need.

If you want to file an appeal, you can:

  • Call 1-800-MEDICARE (1-800-633-4227). The TTY number is 1-877-486-2048. Representatives are available 24 hours a day, seven days a week.
  • Go to the How do I file an appeal? page at Medicare.gov.
  • If you're enrolled in a Medicare Advantage plan or Medicare prescription drug plan, contact your plan for information on the appeals process. You can also contact a State Health Insurance Assistance Program (SHIP) in your area.

Category: Insurance

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