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Navigating the Complexities: What You Need to Know About Medicare and Home Healthcare Coverage

Are you confused about Medicare and home health care coverage? If so, you’re not alone. Navigating the complexities of these topics can be overwhelming.  It’s essential to understand your options and ensure you receive the care you need.

Does Medicare pay for home health care services?

This article will delve into the ins and outs of Medicare and home healthcare coverage, providing the information you need to make informed decisions. We’ll explore the different types of Medicare plans and how they relate to home healthcare services, eligibility requirements, coverage limitations, and common misconceptions.

Whether you’re a senior seeking assistance or a caregiver supporting a loved one, understanding how long Medicare pays for home health care is crucial. By the end of this article, you’ll clearly understand what options are available and how to navigate the complex healthcare landscape.

Stay tuned to discover everything you need about Medicare and home healthcare coverage. Don’t let the confusion hold you back from accessing the care you deserve.

Different Types of Medicare Coverage

Medicare is a federal health insurance program that covers people over 65 and those with specific disabilities or chronic conditions. There are several types of Medicare plans, each with benefits and limitations. Knowing how long each Medicare plan pays for health care is critical. 

Original Medicare, also known as Medicare Part A and Part B, provides coverage for hospital stays, doctor visits, home healthcare, and some medical equipment. Medicare Part C, also known as Medicare Advantage, is a private insurance option combining Parts A and B, often including additional benefits such as prescription drug coverage and dental care.  Both provide home healthcare coverage, but in specific ways unique to the plans.  

Medicare Part D provides coverage for prescription drugs, while Medicare Supplement plans, also known as Medigap, help cover the costs of out-of-pocket expenses not covered by Original Medicare.

Understanding the differences between these plans is essential because they approach home health care differently.  

Understanding Home Healthcare Services

As the name suggests, home healthcare services provide medical care and support to individuals in their homes. This can include services such as nursing care, physical therapy, and speech-language therapy. Home health care is often a more convenient and cost-effective option than hospital or skilled nursing facility (SNF) care and can provide a higher level of comfort and independence for patients. It is skilled nursing care but provided in the home for those who would not have access to medical care otherwise.

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 back your health and independence again.  

For the chronically ill and disabled, the goal of home health care is to maintain the highest level of ability and health.

Home healthcare services can be provided by a variety of healthcare professionals, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists. A physician typically orders services, and they are covered by Medicare and/or private insurance.

Home health care is not home care. Home care would be custodial services like housekeeping, bathing, feeding, etc. Medicare does not usually provide those types of personal services, strictly speaking. There are exceptions, however. On occasion, Medicare allows for a temporary home health aide to assist in the healing process.  

Some injuries and illnesses may last for a long time. While home health care is a necessary service, the bigger question is: how long does Medicare pay for home healthcare?  

Medicare Eligibility for Home Healthcare Coverage

Individuals must meet specific requirements to be eligible for Medicare home healthcare coverage. First, they must be enrolled in Medicare Part A and/or Part B. Both Medicare Part A and Part B provide home healthcare coverage.  

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. The added benefit is Part B does not require a qualifying hospital stay.

The essential requirements of eligibility and access to Medicare home healthcare services are: homebound, physician certification, and Medicare-certified agency care. 

Homebout, in Medicare terms, means that leaving the home requires a considerable and taxing effort. A physician is the gatekeeper of Medicare home healthcare.  The physician certifies and/or recertifies a patient for access to home healthcare.  Finally, a Medicare-certified agency must provide home healthcare services, not any healthcare provider.    

Medicare Part A Coverage

In contrast, Medicare Part A provides 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 Skilled Nursing Facility (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.

Medicare Coverage For Home Healthcare Services Amounts

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 services.
• Eighty percent of the Medicare-approved amount is for durable medical equipment.

Medicare covers a wide range of home health care visits, including skilled nursing care, physical therapy, occupational therapy, speech-language pathology, and medical social services. These services are typically provided part-time or intermittently, depending on the individual’s needs.

Medicare also covers specific durable medical equipment and supplies, such as wheelchairs, hospital beds, and oxygen equipment.

However, coverage limitations and restrictions may apply, and it’s essential to understand what services are covered and how much you may be responsible for paying out of pocket. The agencies providing the equipment and supplies can give details of costs.

Limitations and restrictions of Medicare coverage for home health care

While Medicare provides coverage for many home healthcare services, there are limitations and restrictions to be aware of. For example, Medicare typically only covers part-time or intermittent care and may not cover 24-hour or long-term care.

In addition, Medicare may not cover certain services considered custodial care, such as help with bathing, dressing, and eating. Finally, there may be coverage limitations based on the individual’s medical condition.  Some coverage is subject to annual or lifetime caps.

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

Tips for Navigating Medicare and Home Healthcare Coverage

Navigating the complexities of Medicare and home healthcare coverage can be challenging, but several tips help make the process easier. First, it’s important to understand your needs and choose the Medicare plan that best fits them.

Second, work with your healthcare provider to ensure that a Medicare-certified agency orders and provides home healthcare services. 

Finally, read the fine print and understand any coverage limitations or restrictions that may apply. The Medicare-certified agency is well versed in the cover limitations and costs. Be sure to consult with them ahead of time.  

Alternative options for home health care coverage

While Medicare provides coverage for many home health care services, alternative options may be available to better meet your needs. For example, private insurance plans may offer more comprehensive coverage for certain services.  Medicaid is another route for low-income individuals.

Private Home Health Care Insurance Policies

Home health care insurance is typically a private insurance policy purchased ahead of time to assist Medicare in caring for someone receiving home health care. The policy covers activities of daily living in the home, such as bathing, feeding, transportation, and housekeeping. Like any insurance, these alternative options must be purchased before the health issues arise. Many insurance carriers offer a variety of these types of policies.    

In addition, a variety of community-based programs and organizations offer support and assistance to seniors and individuals with disabilities. These programs may include meal delivery, transportation services, and assistance with daily living activities.

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.

How Long Does Medicare Pay for Home Health Care?

There is no limit to the length of time that a person can receive home health care services. Once the initial qualifying criteria are 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 a certain amount 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 a physician may recertify a patient.  Provided all eligibility requirements continue, he can recertify an unlimited number.

What Happens When Medicare Stops Paying 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 changes because the home health agency decides to reduce or stop providing some or all of the home health services or supplies. Or, the patient’s doctor has changed the orders, which may reduce or stop certain home healthcare services or supplies that Medicare covers.

For example, the doctor changes the care plan from five to three days a week. The agency issues an HHCCN.  The beneficiary receives a notification in writing of the change.

The HHCCN lists the services or supplies that will be changed and gives the beneficiary instructions on what to do if she disagrees. 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 a person’s Medicare-covered services end, 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 contacting 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 detailed notice explaining why it believes Medicare-covered care should end. The agency should tell the applicable coverage rules and other information about the person’s situation.

A physician must submit a statement of appeal to the BFCC-QIO.  It says the patient’s health will be jeopardized if care is discontinued. These factors determine how long Medicare pays for home health care. Knowledge of these rules is vital to maximize benefits and avoid costly mistakes.

Importance of understanding Medicare and home health care coverage

Understanding Medicare and home health care coverage is crucial for seniors and individuals with chronic conditions or disabilities. These programs provide access to essential medical care.  They support individuals to maintain their independence and quality of life.

By understanding the different types of Medicare plans, eligibility requirements, coverage limitations, and alternative options, individuals can make informed decisions about their healthcare and ensure they receive the care they need.

Bottomline: Taking Advantage of Medicare and Home Healthcare Benefits

In conclusion, navigating the complexities of Medicare and home healthcare coverage can be challenging, but it’s essential for seniors and individuals with chronic conditions or disabilities. By understanding the different types of Medicare plans, eligibility requirements, coverage

limitations, and alternative options, individuals can make informed decisions about their healthcare and ensure they receive the care they need.

Whether you’re seeking home healthcare services for yourself or a loved one, working with your healthcare provider and understanding the coverage options available is essential. By taking advantage of Medicare and other home healthcare benefits, you can maintain your independence, improve your quality of life, and ensure you receive the care you deserve.

At Omaha Insurance Solutions, we help you understand the many Medicare rules.  We navigate you through the forms and get the care you need.  Call us at 402-614-3389 to speak with an experienced, licensed insurance agent professional.

 

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.

Medicare Denial Skilled Nursing Facility

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.

Dave’s Scenario

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.

Summary

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.

Maximizing Medicare: Understanding Coverage for Hospice in Skilled Nursing Facilities

Do you or a loved one need hospice care in a skilled nursing facility? Understanding Medicare coverage for this essential service is crucial for maximizing benefits and ensuring quality end-of-life care. This article will explore some of the ins and outs of hospice coverage I didn’t know when my mother was in hospice.  We discuss the question of whether Medicare pays for hospice in a skilled nursing facility.

Navigating the complex world of healthcare can be overwhelming, especially when faced with a difficult situation like imminent death like I experienced with my mother. That’s why I’m here to break it down for you. I’ll explain what hospice care entails, how it differs from other types of care, and, most importantly, what Medicare covers. With this information, you can be confident in your ability to advocate for yourself or your loved one and ensure that all available resources are utilized.

At Omaha Insurance Solutions, information is power regarding healthcare decisions. We aim to make complex topics accessible, providing you with the tools you need to confidently navigate the healthcare system. So, let’s dive in and discover how Medicare can support you during a challenging time.

What is Hospice Care & Who is Eligible?

Hospice care focuses on providing comfort and support to individuals in the final stages of a terminal illness. The goal is to improve the quality of life for patients by managing pain and symptoms while offering emotional and spiritual support to both the patient and their loved ones. Hospice care can be provided in various settings, including skilled nursing facilities.

To be eligible for hospice care, a person must have a life expectancy of six months or less, as certified by a physician. This certification is required for Medicare coverage, which we will discuss further in the following sections. It’s important to note that choosing hospice care does not mean giving up on treatment altogether. It means shifting the focus to comfort and quality of life rather than curative measures.

Hospice care is a holistic approach that addresses individuals’ physical, emotional, and spiritual needs nearing the end of life. It provides a compassionate and supportive environment where patients receive specialized care tailored to their unique needs. Now that we have a basic understanding of hospice care, let’s explore how it relates to skilled nursing facilities and the coverage provided by Medicare.

Understanding Skilled Nursing Facility Care and Medicare Coverage

Skilled nursing facilities (SNFs) are residential facilities that provide round-the-clock nursing care for individuals requiring more intensive medical attention than they could receive at home. SNFs are equipped with trained healthcare professionals, including nurses and therapists, who can address the complex needs of patients. SNF care is often required when individuals have conditions that require ongoing medical monitoring, such as chronic illnesses or post-surgical recovery. Medicare covers certain SNF services, including skilled nursing care, rehabilitation therapy, and medications. However, it’s important to note that not all services provided in a SNF are covered by Medicare, and this includes hospice care.

Medicare Coverage for Hospice in a Skilled Nursing Facility

Medicare provides coverage for hospice care in various settings, including inpatient hospice facilities, the patient’s home, or a skilled nursing facility. However, there are specific criteria that must be met in order for Medicare to pay for hospice care in a skilled nursing facility.

The criteria are the same as for hospice. Firstly, the individual must be eligible for Medicare Part A, which covers inpatient hospital stays, skilled nursing facility care, and hospice care. Secondly, the hospice care must be certified by a Medicare-approved hospice provider. Thirdly, the individual must have a life expectancy of six months or less, as certified by a physician. Lastly, individuals must agree to forgo curative treatments for their terminal illness and receive only palliative care.

The SNF is not primarily providing hospice care. A hospice team coordinates with the SNF to provide the service in the SNF. The location of the hospice care is secondary. The SNF is a location, like the home.  

However, there must be a Medicare-covered reason or treatment to be granted admittance to a skilled nursing facility. The SNF is primarily a medical facility for patients to get better. It is not a hospice facility providing room and board, housekeeping, bathroom transfers, etc.  

Medicare Hospice Benefits for My Mom

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 an ‘I’m in charge’ type of 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 chicken. Who wants to talk about saying goodbye?  I didn’t realize the seriousness of her health situation until much later.  I assumed she didn’t speak about her own death, and I didn’t know how to initiate the conversation.  We were all in different forms of 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).

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 healthcare personnel gave her various painkillers, 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 administered intravenous medications that were faster acting and stabilized her pain level.

During the last visit, it became clear that we could not care for 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 his career and family.

My mother needed around-the-clock care. We asked, ‘Does Medicare pay for hospice in a skilled nursing facility?’ The real question was whether Medicare would pay for a skilled nursing facility while my mother died. Strictly speaking, Medicare does not pay for custodial care. Custodial care is bathing, feeding, toileting, etc. Medicare doesn’t cover room and board if you get hospice care while in a nursing home or a hospice inpatient facility. That is out of your pocket.   

Qualifying for Skilled Nursing Facility Care while 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. Medicare coverage for skilled nursing when you are in hospice is tricky.

The fortunate occurrence, however, was the intravenous nature of my mother’s painkillers. Other than a hospital, you can only receive intravenous medication treatment in a skilled nursing facility. The nature of my mom’s treatment triggered a reason Medicare would accept her being admitted to a skilled nursing facility and pay for it.   

Medicare does cover skilled nursing care after a qualifying hospital stay of 3-days or more. Intravenous medication administration also requires a skilled nursing facility. A home health care nurse showing up several times at home would not be adequate. Also, my mother needed physical therapy to improve her strength after the reaction to the pain. From Medicare Part A and Part B, there were sufficient reasons for Medicare to pay for her stay in the skilled nursing facility (SNF) while she was in hospice.

Does Medicare Pay For Skilled Nursing Care During Hospice?

Strictly speaking, Medicare does not pay for skilled nursing care because someone is in hospice, but other triggering events often 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. Then, they qualify for a skilled nursing stay.  

How to Navigate the Medicare Coverage Process for Hospice in a Skilled Nursing Facility

Navigating the Medicare coverage process for hospice care in a SNF can be complex, but it can be made easier with the correct information and guidance. Here are some steps to help you navigate the process:

1. The first step is to consult with the individual’s physician to determine if they meet the eligibility criteria for hospice care in a SNF. The physician can provide the necessary certification and guidance through the process.  He knows the triggering circumstances that justify a skilled nursing facility stay.  

2. It’s important to choose a Medicare-approved hospice provider with experience providing SNF care. They will be able to guide you through the necessary paperwork and ensure that all requirements are met.  The health professionals are very familiar with Medicare’s billing codes and protocols for admittance to a SNF.  

3. If the individual is already receiving care in a SNF, it’s important to coordinate with the facility to ensure a smooth transition to hospice care. The SNF staff can provide valuable information and support during this process.

4. Familiarize yourself with Medicare’s costs and coverage for hospice care in a SNF. This will help you plan and make informed decisions regarding the individual’s care.

The professionals you deal with know the Medicare rules and the subtleties of maximizing coverage in different circumstances. Listen attentively to their guidance.  

Common Misconceptions about Medicare Coverage of SNF During Hospice 

Several common misconceptions exist about Medicare coverage for hospice care in a SNF. Let’s address some of these misconceptions and provide clarity:

1. Medicare only covers hospice care in certain settings: Medicare provides coverage for hospice care in various settings, including inpatient hospice facilities, the patient’s home, and skilled nursing facilities. As long as the eligibility criteria are met, Medicare will cover hospice care in a SNF.

2. Medicare covers room and board in a SNF. As a rule, Medicare does not cover room and board in a SNF because the individual is receiving hospice care, though room and board may be covered because the patient is in the SNF for reasons other than hospice.  

3. Medicare coverage for hospice care is limited to specific conditions: Medicare coverage for hospice care is not limited to specific conditions or illnesses. As long as the eligibility criteria are met, Medicare will provide coverage for hospice care in a SNF for any terminal illness.

4. Medicare coverage for hospice care is limited to a certain time frame: Medicare does not limit the duration of hospice care coverage in a SNF. As long as the individual meets the eligibility criteria, Medicare will continue to cover the necessary services.

Bottomline: Ensuring Quality Care and Coverage for Hospice in a SNF through Medicare

Maximizing Medicare coverage for hospice care in a skilled nursing facility is essential for ensuring quality end-of-life care. By understanding the eligibility criteria, coverage details, and navigating the Medicare system, you can advocate for yourself or your loved one and ensure all available resources are utilized.

Remember, hospice care is a compassionate and holistic approach that focuses on providing comfort and support during the final stages of a terminal illness. Medicare provides coverage for hospice care in a SNF, including room and board, medications, and necessary medical equipment. By staying informed and proactive, you can maximize Medicare coverage and ensure that the individual receives the care they need.

Burying a mother is one of those milestone events in our lives. While dealing with all the emotional, spiritual, and 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 the wonderful program and the insurance that worked with Medicare.

Phyllis Grimmond 1935-2013 R.I.P.

 

The Bottomline: Benefit Knowledge Makes for Maximum Benefits

At Omaha Insurance Solutions, we understand the importance of access to accurate and reliable information regarding healthcare

decisions. We aim to empower you with the knowledge and resources to navigate the complex world of Medicare coverage. It is important to know that Medicare pays for hospice care in a skilled nursing facility.

By maximizing benefits and ensuring quality care, we can make a difference in the lives of individuals and their loved ones during this challenging time. Call us at 402-614-3389 to ensure you have a Medicare plan protecting you and your loved ones. Speak with an experienced licensed insurance agent profession.   

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:

1. 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.
2. 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.
3. 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.
4. A doctor, or appropriate medical professional, must certify that skilled nursing care is required for recovery.
5. 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.