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.
The Affordable Care Act (ACA) has brought many questions to business owners and individuals alike. What plan is the best? What kind of healthcare will you qualify for? Will you get to keep your same doctors? For those who are retired or close to retirement, the subject can be even more complicated. When you retire or turn 65, do you have to enroll in a Medicare Plan?
Essentially, yes. Joe Baker, president of the Medicare Rights Center, a national, nonprofit advocacy organization, warns that if you don’t enroll in Medicare at the age of 65, “you don’t have primary coverage, which means that you basically don’t have coverage for most of your healthcare needs.”
Many individuals are confused by this, perhaps rightfully so. The fact is, although your health insurance plan bought through an ACA marketplace will not automatically end when you turn 65, its coverage decreases dramatically. The message that Baker and other Medicare professionals are trying to get out to the public is that these individuals who are currently covered by the ACA before turning 65 must enroll in Medicare once they reach that age.
Now, it is important to realize that if you’re 65 or older and are covered by large-employer insurance, this rule doesn’t apply to you; however most people in this situation should at least take Part A, which is hospital insurance. Without this exception however, new Medicare enrollees must apply at least four months after they turn 65, otherwise they’ll have to wait until the next open-enrollment period, with no coverage in the meantime.
Timing is also important when switching from the ACA Marketplace to Medicare coverage; with individuals being warned to take care when they discontinue their exchange coverage as to not leave a gap between that coverage and Medicare enrollment.
The licensed insurance agents at Omaha Insurance Solutions are here to answer any of your questions you may have about Original Medicare, an Omaha Medicare Advantage Plan, and any other Medicare concerns you may have. Please contact us today at (855) 367-3631.
You can also find more information at Medicare.gov.