Medicare Covered ServicesCategory:
All Medicare Advantage (MA) plans must provide at least the same level of coverage for home health care as does Original Medicare, so Medicare Advantage pays for home health care. However, an MA plan may have different rules, costs, and restrictions on services. For example, depending on a person’s MA plan, it may require him to:
- Obtain care from a home health agency that has contracted with the plan.
- Receive prior authorization or a referral before receiving home health care.
- Pay a copayment for home health care.
Center for Medicare & Medicaid Services (CMS) recently announced that Medicare Advantage plan will be able to cover certain types of home health care related services that were not previously able to be offered, beginning in 2019. This will be possible because CMS has expanded the definitional scope of “supplemental benefits” that Medicare Advantage plans can offer. Starting in 2019, insurers can offer additional services to help improve enrollees’ health and quality of life.
Medicare Advantage Can Pay for Home Health Care Supplemental Benefits
Medicare Advantage plans may offer additions benefits not offered by Original Medicare. Previously, CMS did not allow any item or service to qualify as a supplemental benefit. Supplemental benefits were items of “daily maintenance.” In other words, MA plans could not offer items and services that were not directly for medical treatments. The agency has now reinterpreted the requirement for supplemental benefits to include a “primarily health-related” definition as follows:
an item or service that is used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization
Accordingly, this reinterpretation of supplemental benefits will allow Medicare health plans to offer coverage or benefits for the following:
- Adult daycare services are services provided outside the home, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
- In-home support services are services a personal care attendant provides. She assists disabled or medically needy individuals with activities of daily living, such as eating, bathing, and transferring, and instrumental activities of daily living. These activities may include managing money, preparing meals, and cleaning a house. Services must be performed by individuals licensed to provide personal care services, or in a manner that is otherwise consistent with state requirements.
- Home-based palliative care services Medicare does not cover if life expectancy is more than six months. Palliative care (“comfort care”) is to diminish symptoms of a terminally ill patient.
- Transportation for nonemergency medical services is transportation to obtain Part A, Part B, Part D, and supplemental benefit items and services. The transportation must be used to accommodate the enrollee’s health care needs: it cannot be used for nonmedical services, such as groceries or errands.
- Home safety devices and modifications are safety devices to prevent injuries in the home and/or bathroom. The modifications must be non-structural and non-Medicare covered. This benefit can include home and/or bathroom safety inspection to identify any need for safety devices or modifications.
A physician or licensed medical professional must recommend these home care services.
Medicare’s expansion of MA plan benefits, like adult days care, helps patients remain in their homes as they age rather than being institutionalized, which could also result in lower costs for Medicare and Medicaid.
The Advantage of Medicare Advantage for Home Health Care
Medicare Advantage plans may impose different rules, limitations, and costs than Original Medicare, but they must provide at least the same level of home health care benefits.
Starting in 2019, Medicare Advantage plans may offer supplemental benefits that help enrollees with daily maintenance, including transportation for medicare services, in-home support services, and home-based palliative care. Consult the individual MA plan for the details of coverage.
In the Omaha metro area, the MA plans offer some of these benefits. Currently, the plans that do offer a lot of these benefits are the “Dual” or “Special Needs” plans. Those plans are for a person on full Medicaid as well as Medicare or have some special needs because of chronic illness, such as COPD, Diabetes, etc.
In other areas with high population densities, many of the MA plans are much richer with benefits. As it stands in eastern Nebraska and western Iowa, principally Omaha, Lincoln, Bellevue, and Council Bluffs, the supplemental benefits seem to be growing in number and scope each year. A couple of insurance companies recently added transportation to their health plans. More insurance companies are developing Medicare Advantage plans and including this type of home health services.
Home health care is like it sounds. It is the care that takes place in the home. Home health care consists of a wide range of services, like physical therapy, occupational therapy, speech therapy, and nursing care. But, how long does Medicare pay for home health care?
The purpose of home health care is short term treatment for an illness or injury, such as a stroke or broken hip. It is about getting the person healthy and independent again. For the chronically ill and disabled, the goal is to maintain the highest level of ability and health.
Home health care is not home care. Home care would be services, like housekeeping, bathing, feeding, etc. Medicare does not usually provide those types of personal services, strictly speaking.
There are exceptions at times that allow for a temporary home health aide. It is skilled nursing care provided in the home for those who would not have access otherwise. While an excellent service, the big question is: how long does Medicare pay for home health care? Some injuries and illnesses may last for a long time.
Medicare Part A and Part B both provide coverage for home health care. Under Part B, a person is eligible for home health care if she is homebound, requires skilled care, and is certified as needing care by a physician. Medicare Part B covers most home health care. The added benefit is Part B does not require a qualifying hospital stay.
Medicare Part A Coverage
Part A, in contrast, does provide home health care coverage in some situations. A hospital or skilled nursing facility stay triggers Part A. If a person has a three-day inpatient stay at a hospital or has a Medicare-covered SNF stay, Part A will cover up to 100 days of home health care.
Note that a person must still meet the other eligibility requirements to receive home health care, such as needing skilled care, being homebound, and having a doctor certify that such care is necessary. A person also must receive home health services within 14 days of being discharged from a hospital or SNF. If a person doesn’t meet all of the requirements for Part A coverage but is otherwise eligible for home health care benefits, her care will be financed under Part B.
Regardless of whether Part A or Part B covers a person’s care, Medicare will pay:
- the entire approved cost of all covered home health visits
- 80 percent of the Medicare-approved amount for durable medical equipment
Certified Home Health Agency Disclosure of Covered Costs
Before home health care starts, the certified home health agency must tell the person how much Medicare will pay. The agency must also disclose if Medicare does not cover needed items or services. Then tell how much the person will have to pay for them.
For example, charges to a person may be:
- medical services and supplies that Original Medicare doesn’t cover, such as prescription drugs or routine foot care
- 20 percent of the approved amount for Medicare-covered durable medical equipment such as wheelchairs, walkers, and oxygen equipment
Home Health Agency Advance Beneficiary Notice of Noncoverage
When a certified home health agency believes that Medicare may not pay for some or all of a person’s home health care, it must give the person a written notice called an Advance Beneficiary Notice of Noncoverage (ABN). The ABN might occur, for example, if the home health agency thinks that Medicare will not pay for items or services because:
- The care is not considered medically reasonable and necessary.
The care is only unskilled, a home health care aide, like help with bathing or dressing.
- The person is not homebound.
- The person does not need skilled care on an intermittent basis.
The ABN must describe the service and/or items that may not be covered and explain why Medicare probably won’t pay. The notice must also include an estimate of the costs for the items and services, so that the beneficiary can decide whether to receive the services, understanding that she may have to pay out-of-pocket for such care.
The ABN also gives directions for getting an official decision from Medicare about payment for home health services and supplies and for filing an appeal if Medicare won’t pay.
Home Health Care Length of Coverage
There is no limit to the length of time that a person can receive home health care benefits. Once the initial qualifying criteria is met, Medicare will cover home health care as long as it is medically necessary. However, care is limited. There are a maximum number of visits per week and number of hours per day of care.
When a person first begins receiving home health care, the plan of care will allow for up to 60 days. At the end of this period, the physician must decide whether to recertify the patient for another 60 days. The patient must be recertified at least every 60 days if home health care is to continue.
Medicare does not limit the number of times that a physician may recertify a patient for home health care benefits, provided all of the eligibility requirements continue.
How Long will Medicare Pay for Home Health Care?
A home health agency must give a beneficiary a written Home Health Change of Care Notice (HHCCN) when the patient’s plan of care is changing because the home health agency makes a business decision to reduce or stop providing some or all of the home health services or supplies.
The person’s doctor has changed the person’s orders, which may reduce or stop certain home health care services or supplies that Medicare covers.
For example, the agency issues an HHCCN when the doctor changes the plan of care from five days a week to three days a week. The beneficiary must be notified in writing of the change of service.
The HHCCN lists the services or supplies that will be changed and gives the beneficiary instructions on what to do if she does not agree with the change.
The home health agency is not required to give a person an HHCCN when a Notice of Medicare Noncoverage is issued.
Notice of Medicare Noncoverage
When all of a person’s Medicare covers services are ending, the home health agency must give the beneficiary a Notice of Medicare Noncoverage (NOMNC). This notice states when services will end as well as how to appeal the decision. The NOMNC also provides information on how to contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) to request an expedited appeal.
Once a person decides to appeal and has reached the BFCC-QIO, the home health agency must give the patient a more detailed notice explaining why it believes Medicare-covered care should end. The agency should tell the applicable coverage rules and other information specific to the person’s situation.
A physician must submit a statement of appeal to the BFCC-QIO that the patient’s health will be jeopardized if care is discontinued.
All of these factors go into how long Medicare pays for home health care. Knowledge of these rules is important so that you can maximize your benefits and avoid costly mistakes.
Medicare covers Home Health Care, but the Medicare beneficiary must meet particular criteria, maintain a status of medical need, and follow Medicare regulations and processes to enjoy the benefits.
- A physician must certify that skilled care is needed and must prescribe the plan of care.
- A participating Medicare-approved home health care organization must provide the care.
- The patient must need at least one of the services: intermittent skilled nursing care, physical therapy, speech-language pathology, and continued occupational therapy.
- The patient must be confined to the home.
A physician must meet face-to-face with the patient 90 days before the start of home health care or within 30 days after the start of home health care. She must sign and date a certification that the patient needs skilled care and meets all the Medicare eligibility criteria for home health care. As part of the certification, she must determine from the in-person meeting a plan of care.
- A plan of care describes the type of services and care a person will receive for their health concerns. The program will list:
- the variety of services, supplies, and equipment needed.
- the health care professional who will deliver these services
- how often services will be needed
- the beneficiary’s function limitations
- nutritional requirements]
- the results that the physician expects from the treatment
The home health agency is responsible for providing all of the care listed in a person’s plan of care. The agency may do this through its staff or an arrangement with another agency.
The doctor certifies the person as eligible for an initial 60-day benefit period. At the end of the period or before, the doctor may recertify the person, or if the person’s condition has changed, determine the care is no longer needed. Only the doctor can certify the patient or make changes to the plan of care, not the home health agency.
Medicare-Certified Home Health Care Agency
Medicare will pay for home health care only if a Medicare-certified home health care agency provides it. Medicare approves agencies that meet specific federal health and safety requirements as well as Medicare standards necessary for reimbursement. To ensure that these standards met, Medicare regularly inspects home health agencies. However, Medicare certification does not guarantee a legal warrant of the individuals performing the services.
A Medicare-certified home health agency agrees to:
- be paid by Medicare
- accept only the amount that Medicare approves for its services.
The patient has the right to choose any agency to provide the services as long as they are Medicare certified. The agency is not required to accept the person if it cannot meet that person’s medical needs.
Skilled Care Required But Intermittent
To qualify for Medicare provided home health care, the person needs specialized care. Skilled care means services, such as skilled nursing care, physical therapy, speech therapy, and/or continuing occupational therapy.
The key to determining home health care versus skilled nursing care in a facility is the quantity of care. Home health care must be intermittent. That is, the care must be part-time, meaning less than eight hours each day for up to 21 days–although coverage may be extended in particular circumstances when the need for additional skilled nursing is finite and predictable.
The homebound criterium does not mean the person is a prisoner in her home. It means leaving is an undue burden. She has trouble leaving home without help because she must use a cane, wheelchair, walker, crutches, or specialized transportation.
It does not mean that person does not leave home on occasion because of important family events, specific medical tests, funerals, or weddings. Even attending adult daycare would not be a violation of being homebound.
Home Health Care May Cover A Health Aide
Home health aide services get a great deal of play. Medicare will cover a health aide for short periods. The aide service must be coupled with home health care services. Medicare does not cover it exclusively.
The home health aide is in support of the healing process with the other skilled nursing professionals. The home health aid does not have a nursing license. For example, a home health aide might help a person with personal care, such as bathing, using the toilet, or dressing–in other words, services that do not require the skills of a licensed nurse.
Other services are help with medications that are self-administered, assistance with activities that are directly supportive of skilled therapy. The aide may help with routine exercises and/or practicing functional communication skills. Where appliable, she may help with regular care of prosthetic and orthotic devices. Medicare will not cover the home health aide if the patient is not receiving skilled care.
Home Health Care Can Cover Social Services
Many injuries and illnesses come with an emotional cost. A patient of my wife recently was hospitalized because his son assaulted him while under the influence of illegal drugs. He was defending his wife, who was likewise being assaulted. The father was hospitalized with broken bones. He is also currently going through chemotherapy treatment and is eighty-six years old.
As you can imagine, the emotional trauma to this couple was extensive and may require counseling and other intervention when the gentleman returns home. Home health care provides these types of services as well.
Durable Medical Equipment
Home health agencies will also help with durable medical equipment. A patient may need a hospital bed, walker, wheelchair, or oxygen. Medicare also covers Medicare supplies, like wound dressings or catheters that are ordered as part of a patient’s care.
If a home health agency doesn’t supply durable medical equipment directly, its staff will typically arrange for a home equipment supplier to bring the items need to the person’s home.
Does Medicare Exclude Some Home Health Care Services?
Medicare does not pay for the following:
- 24-hour-per-day care at home
- meals delivered to the home
- homemaker services like shopping, cleaning, and laundry
- personal care given by home health aides (like bathing, using the toilet, or help in getting dressed)when this is the only care needed.
Does Medicare cover home health care? It certainly does when the patient meets the established criteria. Home health care is a rich source of benefits to beneficiaries that are delivered in a variety of ways and circumstances as needed.
We know what hospitals are. We all have been to a doctor’s office. Many have experienced a relative in a nursing home, but what is home health care?
Home health care is like it sounds. It is the care that takes place in the home. It consists of a wide range of services, like physical therapy, occupational therapy, speech therapy, and nursing care.
The purpose of home health care is short term treatment for an illness or injury, such as a stroke or broken hip. It is about getting the person healthy and independent again. Or, it is for the chronically ill and disabled. The goal is to maintain the highest level of ability and health.
Home health care is not home care. Home care would be services, like housekeeping, bathing, feeding, etc. Medicare does not usually provide those types of personal services, strictly speaking, though there are exceptions at times that allow for a temporary home health aide. It is skilled nursing care provided in the home for those who would not have access otherwise.
Does Medicare Cover It?
Four criteria must be met for Medicare to pay for home health care.
- A physician must certify home health care is necessary.
- The home health care provider must be a Medicare-approved organization.
- The patient must need at least one of the following: skilled nursing care, physical therapy, occupational therapy, or speech therapy.
- The patient must be homebound.
Doctor Certifies Patient For Home Health Care
The doctor must certify a patient needs home health care during an in-person meeting. He signs a certificate certifying that the person meets the Medicare qualification. The doctor lays out a plan of care that care professions implement, and the certification is for 60 days. At the end of the 60 days, or before, he can recertify that patient for an additional 60 days.
The doctor can continue to recertify the patient indefinitely as long as the person qualifies for the medically necessary treatment, and Medicare will continue to cover them.
Home Health Agency Medicare Certified
The home health agency providing the care must be certified by Medicare for the service to be Medicare-covered. In my office building as you come in, a care agency is in the lobby. On the office door, the home health agency lists the various services, and in even bigger letters, it states, “Medicare Certified.”
Medicare certification of a home health agency is an extensive process. Because accreditation is arduous and a source of considerable revenue, home health agencies are very careful about maintaining their certification and advertising their Medicare certification as well. The Omaha metro area has some excellent home health care agencies.
Home health care must also be intermittent care. That is, it consists of fewer than seven days a week, or daily care for less than 8 hours each day for up to 21 days. Otherwise, a skilled nursing facility would most likely be recommended for a more intense regimen of care.
The patient must be homebound, which means she cannot leave her home without great difficulty and requires help, such as a wheelchair, walker, crutches, or specialized transportation. It doesn’t mean she can never leave her home for important things, like family events, hairdressing appointments, some doctors’ appointments, but getting regular health services outside the house would be an undue burden.
People are living longer. Tremendous advances in technology have enabled seniors to stay out of expensive skilled nursing care. Nowadays, patients may receive very sophisticated treatment at home and do not need to be institutionalized, keeping the cost of treatment lower. It is an important and essential service that Medicare covers.
Jimmo vs. Sebelius On Skilled Nursing
Skilled Nursing Care is amazingly complex. Because the Medicare coverage of Skilled Nursing Facility stays is so confusing, patients sued. The case went all the way to the Federal Courts. Jimmo vs. Sebelius, a class-action lawsuit, challenged the Center For Medicare & Medicaid Services (CMS) interpretation of the “improvement stand” that many used to interpret Medicare coverage of Skilled Nursing Facility booklet.
Medicare Coverage of Skilled Nursing Facility Stays: Improvement Standard
This one hit home for me because of how it affected my mother and our family. My mother was in the last stages of ovarian cancer. It became clear that no treatment was going to work. She was on palliative care. During one of her episodes, she was in extreme pain. The hospital admitted my mother because intravenously administered pain killers were the only way to get her pain under control. After that, she was supposed to come home. But her condition was such that we were not going to be able to care for her adequately. We talked about a nursing home—skilled nursing—but one of the criteria at the time was the patient must be able to improve. Because she was terminal, improvement was definitely not in the cards. We were initially told that Medicare would not pay for her stay in a skilled nursing facility. However, that was not accurate. The people we were talking with were operating off old, outdated information.
Slow Deterioration of a Condition
On January 24, 2013, the class action lawsuit Jimmo vs Sebelius settled in favor of the patient, and the Center for Medicare & Medicaid Services (CMS) clarified its policy. Medicare coverage of Skilled Nursing Facility stays no longer required “improvement.” Instead, care could be prescribed to maintain the status of an individual’s condition, or slow the deterioration of a condition, as well as to improve the person’s condition.
Jimmo Website Explains New Medicare Coverage
As ordered by the federal judge in Jimmo v. Sebelius, the Centers for Medicare and Medicaid Services (CMS) published a new webpage containing important information about the Jimmo Settlement on its CMS.gov website. The Jimmo webpage is the final step in a court-ordered Corrective Action Plan. The action reinforces the fact that Medicare does cover skilled nursing and skilled therapy services needed to maintain a patient’s function or to prevent or slow decline. Improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities.
In my mother’s case, the skilled nursing facility admitted my mother, even though she was terminal, to help slow the deterioration of her health. As it turned out, she passed away within two weeks of her admittance, and the personnel at her skilled nursing facility were outstanding! They made her last days as bearable as the situation would allow.
Medicare Coverage of Skilled Nursing Facilities Changed
Medicare coverage of Skilled Nursing Facility stays practices have changed. Researchers assessed the impact of the Jimmo settlement by looking at changes to the number of physical therapy and/or occupational therapy visits per year, per patient, focusing specifically on the number of individuals who had 12 or more therapy visits during a 12-month timespan.
Healthcare is very expensive. There are many conflicting groups and interests. The rules, policies, and mechanisms are complex. Some of the people you deal with can be frustrating. The complexity of the system is driven home to me daily as I talk with clients and deal with issues that arise. You need to be aware of the rules and regulations around Medicare coverage and nursing home care. Or have someone who knows them and can help.
Medicare Coverage For Skilled Nursing Facilities
Skilled Nursing Facilities—or better known in the jargon of Medicare as SNF—is the cause of much consternation among people on Medicare. The reason for the distress and stress is because Medicare beneficiaries are sometimes denied coverage. This both confuses and angers Medicare beneficiaries because there doesn’t seem to be any rhyme or reason to the denials. People ask: does Medicare cover Skilled Nursing Facility?
Medicare Billing Guidelines For Skilled Nursing Facility
From my observation over the years, doctors’ offices sometimes don’t follow the Medicare billing guidelines for Skilled Nursing Facility. I understand everyone is busy and people are certainly well-intentioned, but Medicare is insurance. Insurance has rules, protocols, and forms. A lack of adequate explanation to Medicare is many times the cause of Medicare denials, I’ve seen over the years. Other times the situation does not meet the Medicare criteria for Skilled Nursing Facility stays.
What are the Medicare Skilled Nursing Facility Requirements?
When skilled nursing is prescribed, five Medicare Skilled Nursing Facility requirements must be met. The first is a qualifying hospital stay.
The Medicare beneficiary must stay as an inpatient for three consecutive days in the hospital. Each of these is an essential ingredient. The beneficiary must be admitted to the hospital. If the patient is only admitted for “observation,” she will not qualify. She must be an “inpatient.” Next, the stay must be consecutive. It can’t be a day or two within a short period of time. It must be at least 3 consecutive days. And finally, it must be at least 3 days, not counting the day of dismissal.
Many times, people assume the day of dismissal counts, but that is definitely not the case. Three days of inpatient care at least with a fourth day for the dismissal. Sometimes people will complain that the patient doesn’t need a third day, but if you want the person to qualify, she must stay at least three consecutive days.
Medicare Skilled Nursing Facility Benefit Period
The second ingredient for Medicare to cover a skilled nursing facility stay is the admittance must occur with 30 days of dismissal from the qualifying hospital stay.
My mother-in-law had open heart surgery a while back. Her cardiologist prescribed that she stay in a skilled nursing facility for cardiac rehab. She was not a very cooperative patient. She refused. My wife was insistent and explained that if she didn’t go then, she would lose the opportunity for skilled nursing rehab. My mother-in-law’s response was she would do it later if she needed it.
Many people mistakenly think they can go to a nursing home for rehab if they simply want to. It must be within the 30-day window after dismissal from an inpatient stay. Otherwise, Medicare will not pay. Now you may think it is not fair, or right, or make sense. I am simply stating the rules and facts.
Medicare Guidelines for Skilled Nursing Facility
The third requirement for admittance to a skilled nursing facility (SNF) is the treatment can only be provided by a skilled nursing facility.
What this usually means is “full time” or five day a week care. In other words, the same level of treatment cannot be provided by going to a treatment center by appointment a few times a week. Only an inpatient skilled nursing facility can provide the level of intense treatment needed for adequate recovery. This can be a tricky call and where judgments can and are questioned.
I had a client who had a knee replacement. Usually a knee replacement, even with complications, does not require admittance to a skilled nursing facility (SNF) because physical therapy is something that can be completed by going to the physical therapist’s office and/or doing exercises on your own. This situation was different.
She was living in a small apartment with lots of furniture. There was a pet. The husband was feeble. While she was not very old, her knee was not recovering at the usual pace. The doctor recommended skilled nursing care, but Medicare denied the prescription.
The family came to me with questions. I suggested they explain the situation to the doctor in greater detail and with more urgency. She was a serious “fall risk” because of her living situation.
Once the idea was emphasized sufficiently in the doctor’s notes to Medicare, Medicare understood that the work that had been done would be undone if she fell at home because of a pet, furniture, and/or feeble husband, etc. The request was approved.
Skilled nursing is very expensive. Medicare needs to understand the “medical necessity” of a prescription. Once the idea is communicated effectively, things can happen.
List of Medicare Approved Skilled Nursing Facilities
The fourth ingredient is that a doctor, or another appropriate medical professional, certifies that the patient needs the type of daily therapy that can only be performed in a skilled nursing facility. The skilled nursing facility must also be a Medicare-certified skilled nursing facility. You can go to Medicare.gov to find certified sites and Medicare the star ratings for Skilled Nursing Facilities.
The fifth and final requirement can be confusing. The skilled nursing care must be for the reason the patient was in the hospital for the three days.
Imagine John goes to the hospital because of a broken hip. While John was in the hospital, he has a stroke. The doctor certifies John for treatment at a skilled nursing facility for the stroke, not the hip issue. The skilled nursing recommendation does not have to be based on the reason the person was admitted to the hospital, but it does need to be because of something he was treated for during the 3-day hospital stay.
As you can see, Medicare coverage for skilled nursing facilities can be complex. It’s important to have some understanding so that you know what to expect, or not to expect, when it comes to Medicare coverage of skilled nursing facility care, and how to navigate the processes to your benefit and the benefit of loved ones. Medicare Part A covers the Skilled Nursing Facility, but the rule must be followed for Skilled Nursing Facility Medicare reimbursement to happen.
The chances are you or someone in your family will require skilled nursing care because of a serious injury, stroke, or surgery. Twenty-five percent of skilled nursing stays are less than three months. Many, however, are longer. Nursing home care costs vary from state to state and location to location. The questions my clients ask are: how long does Medicare pay for skilled nursing care?
Skilled Nursing Care Costs Are High
Depending upon the state in which you reside, the daily costs associated with nursing home care vary widely between $140 and $771 per day for a semi-private room in 2017. The average cost was $235 per day for a semi-private room. Multiplying that out the monthly cost associated with skilled nursing care ran anywhere between $4,258 and $23,451 per month for a semi-private room, with the average being closer to $7,148 each month for a semi-private room. For most people, those are prohibitive costs!
How Much Skilled Nursing Does Medicare Pay For?
Many of my clients will call when faced with the possibility of going into a skilled nursing facility. Illness is scary enough. You don’t want to worry about overwhelming medical bills. My people want to know they’re covered. They want to know how much skilled nursing does Medicare pay for. Do Medicare Advantage plans cover skilled nursing facilities? Do Medicare Supplements cover skilled nursing facilities? So, the big question is: who pays?
Medicare Skill Nursing Benefit Period Is 100-Days
So, how many days does Medicare cover skilled nursing facility care? The Medicare Skilled Nursing Facility (SNF) benefit period, or “Spell of care,” is 100 days. The benefit period ends when the patient leaves the SNF for 3o days, and a new 100 day benefit period is available after 60 days.
Skilled Nursing Facility’s Legal Obligations
When a patient leaves a hospital and moves to a nursing home that provides Medicare coverage, the nursing home must give the patient written notice of whether the nursing home believes that the patient requires a skilled level of care and thus merits Medicare coverage. Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will issue a “Notice of Non-Coverage” terminating the Medicare coverage.
Whether the non-coverage determination is made on entering the SNF or after a period of treatment, the patient can submit or not to Medicare. The patient (or his or her representative) should always ask for the bill to be submitted. This requires the nursing home to submit the patient’s medical records for review to the fiscal intermediary, an insurance company hired by Medicare, which reviews the facility’s determination. The review costs the patient nothing and may result in more Medicare coverage. While the review is being conducted, the patient is not obligated to pay the nursing home. However, if the appeal is denied, the patient will owe the facility retroactively for the period under review.
If the fiscal intermediary agrees with the nursing home that the patient no longer requires a skilled level of care, the next level of appeal is to an Administrative Law Judge. This appeal can take a year and involves hiring a lawyer. It should be pursued only if, after reviewing the patient’s medical records, the lawyer believes that the patient was receiving a skilled level of care that should have been covered by Medicare. If you are turned down at this appeal level, there are subsequent appeals to the Appeals Council in Washington, and then to federal court.
Day 101 You Pay
If you need more than 100 days of SNF care in a benefit period, how many days will Medicare pay for skilled nursing care? Nothing. SNF is meant to be short term. You will need to pay out of pocket if your care ends because you are run out of days. The SNF is not required to provide written notice. It is important that you or a caregiver keep track of how many days you spend in a SNF to avoid unexpected costs after Medicare coverage ends.
How Else to Pay For Skilled Nursing Care
If you are receiving medically necessary physical, occupational, or speech therapy, Medicare may continue to cover those skilled therapy services even when you have used up your SNF days in a benefit period, but Medicare will not pay for your room and board, meaning you may face high costs.
Medicare does not cover long term care or custodial care. You may wish to move to a home health care situation at that point. Medicare pays for home health care, and the costs are much less. If you have long-term care insurance, it may cover your SNF stay after your Medicare coverage ends. If your income is low enough, you may be eligible for Medicaid to cover the cost of your stay.
Unlimited Skilled Nursing Benefit Periods
Once you are out of skilled nursing for 60 days, your SNF benefit period ends, but you may become eligible again for another SNF benefit period after a qualifying hospital stay of 3-days. There is no limit on the number of benefit periods available to a Medicare beneficiary as long as the Medicare requirements are met.
In other words, a person could potentially keep going into Medicare covered skilled nursing care every 100 days after a 60-day break as long as it is preceded by a qualifying hospital stay of 3-days. While repeat 100 day stays in a skilled nursing facility are not likely, that does give an idea of the level of incredible care available to a Medicare beneficiary.
NO Insurance: $176 Per Day
Medicare Supplements and Medicare Advantage plans pick up large portions of the 100-benefit period. The amount covered depends on the type of Medicare Supplement plan and Advantage plan. If the patients has neither, just Original Medicare, she is responsible for 21-100 days. The per day cost is currently $176 (2020).
30 Or 60 Days
An important note on the number of days out of a Skilled Nursing Facility approved stay. If a patient has left the SNF for 30-days or less, she may return without a 3-day inpatient hospital stay to initial the stay, but the 100-day count continues from where it left off. If the patient has been out of the SNF for 60-days for less, but more than 30-days, she will need another 3-day hospital stay for Medicare to pay for the time in the Skilled Nursing Facility. And the 100-day count continues from where it left off. After 60 consecutive days without SNF care, a new benefit may begin. There is no limit to the number of benefit periods.
Let’s layout some common scenarios. You might need your calculator or at least your fingers and toes to keep track.
Imagine David is in the hospital for 4 days because of a stroke. He is then admitted to a skilled nursing facility for 20 days. Dave leaves the skilled nursing facility for 28 days, but he has a complication. Dave falls going to the bathroom. The doctor readmitted him into the nursing home. He is within the 30-day window. No problem. Medicare will pay for that.
If, however, David was out of the nursing home 31 days, and he fell, he would need another 3-day stay in the hospital to be readmitted to the skilled nursing facility so Medicare would pay. Dave’s doctor may or may not be able to get him re-admitted to the hospital based upon his medical condition.
Skilled Nursing Facilities (SNF) are incredibly expensive. How long does Medicare pay for Skilled Nursing Care? Medicare does cover a 100-day benefit period. Medicare Supplements and Medicare Advantage plans cover large portions of the stay, depending on the plan. The cost, however, starting day 21 is $176 per day to patients without any additional coverage. The 100-day benefit period has very strict rules when it begins and ends. There are rules to which you need to be attentive to avoid unexpected and large bills, and it is worth talking with your insurance agent to make sure you have the maximum amount of coverage you can afford.
My Mother’s Life Expectancy
The doctors diagnosed my mother with ovarian cancer in 2012. I was living in Kansas at the time. I wasn’t able to go on doctor visits with her. My brother, Paul, was taking care of my mom. I would get information about her situation, but it was spotty. My mother was definitely ‘I’m in charge’-type person. Phyllis determined the flow of information, and it was sparse.
Talking with your mother about her health when her mortality is so tightly fixed to it is hard. Looking back now, I was a coward. I should have been more direct. I didn’t realize the seriousness of her situation until much later. She didn’t speak of her death, I assumed, because she didn’t want to worry us though I am sure she was struggling with her own denial.
At the end of 2012, the doctors said there was nothing more to be done. I don’t think I fully grasped what that meant at the time. I also did not anticipate how quickly time would slip away from that moment onward. I’m sure my mother was scared, but she didn’t let on. I stupidly didn’t realize the magnitude of the moment and how she was probably feeling. My own feelings and denial fogged the situation.
My mother was admitted to hospice care (Medicare Hospice Benefits Booklet).
Medicare Hospice Benefit
Hospice care is a benefit under Medicare Part A. To be eligible to elect
hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the
medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare-certified hospice is covered under the Medicare hospice benefit.
The hospice admits a patient only on the recommendation of the medical director in
consultation with, or with input from, the patient’s attending physician.
Mom’s Terminal Illness
Nature, in its less than glorious side, took its course rapidly. My mother’s health deteriorated in a few short weeks.
Cancer is a painful disease. The health care personnel gave her various pain killers, but even as they did so, we all insanely talked about not wishing to cause addiction. The pain had its own mind. At various times, my mother’s suffering would be such that she needed to go to the hospital. There the doctors could administer intravenous medications that were faster acting and could stabilize her level of pain.
During the last visit, it became clear that we could not take care of her at home. My father, John Grimmond–who would pass away six months later–was not physically able to care for our mother. I was in Kansas, my other brother, Tom, was in Sioux Falls, and Paul was in Omaha but busy with career and family. My mother needed around-the-clock care. We asked ‘does Medicare pay for hospice in a skilled nursing facility?’ Medicare pays for hospice in a skilled nursing facility, but Medicare does not strictly pay for custodial care. That is, it will not pay for bathing, feeding, going to the toilet, etc.
How To Help Mom With Medicare On Hospice
The staff at the hospital initially told us that our mother needed to go to a Skilled Nursing Facility (SNF) because they recognized she required more care than we could provide. They informed us that Medicare would provide and pay for hospice care in the Skilled Nursing Facility, but the cost of room and board and custodial nursing care would not be covered, and they were correct.
The fortunate occurrence, however, was the intravenous nature of her pain killers triggered a reason for skilled nursing care. Medicare does cover skilled nursing care after a qualifying hospital stay of 3-days or more. Intravenous medication administration requires skilled nursing care. A home health care nurse showing up a couple of times at home would not be adequate to the task. Also, she needed physical therapy to improve her strength after the reaction to the pain. Those were sufficient reasons for Medicare to cover her stay in the skilled nursing facility (SNF) and to pay for even the room and board.
Does Medicare Pay For Skilled Nursing Care During Hospice?
Does Medicare pay for hospice care in a skilled nursing facility? Strictly speaking, Medicare does not pay for skilled nursing care because someone is in hospice, but many times there are other triggering events that cause Medicare to cover skilled nursing care. For example, someone who is in hospice falls and breaks a hip. That situation would justify skilled nursing care. A person develops an infection or pneumonia that results in hospitalization. The patient is transferred to a skilled nursing facility to continue the care. In those ways, skilled nursing and the custodial care that accompanies it are available.
Burying a mother is one of those milestone events in our lives. While dealing with all the emotional, spiritual, financial challenges that accompanied that moment, health care cost was not a burden to my family and me. Medicare and my mother’s Medicare plan took excellent care of her and us. I am grateful for such a wonderful program and the insurance that worked with Medicare.
What Are Skilled Nursing Facilities?
All of us have strong memories of visiting the “old folks’ home.” Whether grandparents, relatives, or friends, we recall the smells, linoleum, long hallways, and institutional dormitory rooms. “Old folks’ homes” or nursing homes fall under the category of Skilled Nursing Facilities (SNF). Medicare covers skilled nursing facilities within limits.
Patients go to the SNF after surgeries to recover, from illnesses to heal, and from injuries to recover and strengthen. Skilled Nursing Facilities are for temporary treatment, not long term residential care or custodial care, like memory care. Other facilities, like senior living communities, assisted living, or senior care centers describe other types of facilities that assist seniors.
A skilled nursing facility provides highly skilled professionals, such as occupational therapists, physical therapists, registered nurses, speech therapists. The advantage of an SNF is these professions are available 24 hours a day for the patients. The level of care is very high but short term.
Post-Acute & Skill Rehab Services
Skilled Nursing Facilities are institutions that provide post-acute skilled nursing care and rehabilitation services. People sometimes confuse skilled nursing care with nursing home care because most of the time skill nursing usually takes place in a nursing home location. Medicare, however, doesn’t pay for “nursing home care”.
Medicare covers skilled nursing facilities within specific parameters. Nursing home care is for individuals who have reached a point in life when they can no longer perform activities of daily living. This is referred to as custodial care. In other words, they cannot bath, feed, and dress themselves. Medicare will not pay for those services to be provided exclusively.
Skilled Nursing is for after surgery or acute illness, for example, hip surgery for a fractured hip or a stroke. A skilled nursing facility admits patients for a short period of time after being in the hospital to aid in their healing and/or rehabilitation. Hospitals are incredibly expensive, and a skilled nursing facility can provide the necessary treatment at a lower cost.
Medicare Criteria For Skilled Nursing Facilities
The tricky part about skilled nursing facilities is admittance. A skilled nursing facility requires patients to meet certain essential criteria for admittance and for Medicare to pay. This is the complex checklist:
- The patient must be admitted to a hospital as an “inpatient” for at least three consecutive days, not including the day of dismissal. She can’t be in the hospital for “observation” for it to count for Medicare to pay.
- Medicare mandates patient admittance to the skilled nursing facility within 30 days of discharge from the hospital. If problems arise later—past 30 days—the patient cannot go to the skilled nursing facility and have Medicare pay for it.
- Only a skilled nursing facility can provide the type of care necessary for the patient’s recovery. A skilled nursing facility would provide intense physical therapy for a hip injury or occupational therapy after a stroke. Going to the physical therapist’s office a couple of times a week would not be sufficient in those cases.
- A doctor, or appropriate medical professional, must certify that skilled nursing care is required for recovery.
- The patient must be treated for the same condition for which she was in the hospital.
There are nuances and exceptions to some of these rules. The list gives you a good idea about how skilled nursing fits into your Medicare health insurance. The Omaha, NE area has many quality Medicare certified facilities, and You can find them on the Medicare.gov website.