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Medicare only pays for short-term skilled nursing facility care, which amounts to only about 10% of all nursing facility costs nationwide. Medicare does not cover long-term nursing facilities, assisted living, or other residentical care. Medicare’s coverage of home care is also extremely limited, paying only for short-term home health care while someone recovers from an illness, an injury, or surgery.

Most americans age 65 and older are eligible for Medicare coverage, but few understand how it works. Medicare is a federal government program created to assist older Americans with medical costs. The program is divided into two parts. Part A is “hospital insurance” which covers some of the bills for a say in a hospital or a skilled nursin facility. Part b is “medical insurance” which pays some of the costs of doctors and outpatient medical care.

One of the worst misconceptions about Medicare is that it covers nursing facility care. In Fact, Medicare nursing facility coverage is severly limited, which means most people must pay for virtually all long-term care out of their own pockets. Medicare pays much less for home care than such logic might lead you to expect. And it pays nothing at all for custodial care in nursing facilities or other residential long-term care facilities.

But it’s important to find out what Medicare does not pay for, so you can be prepared either to gather the funds elsewhere or obtain most of your care and coverage from other sources.

Medicare Skilled Nursing Facility Care Part A
Only covers:

  • up to 100 days per benefit period. That is, per continious period of treatment in a skilled nursing facility.
  • A semiprivate room (2-4 beds); if you want a private room, you must pay the different in cost yourself, unless the private room is medically necessary as prescribed by a doctor and approved by the facility and the Medicare intermediary.
  • daily, regular, skilled, and special nursing as medically necessary, but not a privaty-duty nurse
  • Skilled rehabilitation services -such as physical, occupational, or speech therapy- if medically necessary,
  • medications, medical supplies and equipment and dietary requirements as supplied by the facility.

What isn’t covered by Medicare Part A.
Medicare part A does not cover:

  • custodial care (nonmedical assistance with normal daily activities such as eating and bathing), unless it is part of skilled nursing care in a skilled nursing facility.
  • Nursing care or therapy provided in a facility that is not certified by Medicare as a kskilled nursing facility
  • Doctor’s care while you are in a nursing facility.

Requirements for coverage:

  • Immediate prior hospital stay. Medicare pays for your stay in a skilled nursing facility only if you have first spent at least 3 consecutive days (not counting the discharge day) in a hospital. You must be admitted to the nursing facility within 30 days of your discharge from the hospital.
  • Daily skilled nursing care or therapy. Medicare pays only for the skilled nursing care or rehabilitative therapy you need and receive every day. if you receive such care intermittently, you do not qualify for Medicare coverage.
  • Prescribed by a physiciain. Your daily skilled nursing care or therapy must be “medically necessary” -that is, it has to be specifically prescribed by a doctor.
  • Medicare-approved skilled nursing facility. you must receive care in a skilled nursing facility certified by Medicare. Medicare won’t cover care that is, or could be, receved in a lower-level facility.
  • Only until condition stabilizes. Medicare will cover your inpatient stay in a skilled nursing facility only until your condition stabilizes. This means that coverage can continue, up to 100 days, while you need inpatient skilled nursing care to improve your conditionr or to keep your condition from getting worse. once your condition has stabilized, Medicare will no longer pay for a stay in a skilled nursing facility, even if you still require some skilled nursing care and have not yet used up your 100 days of coverage.
  • Approval on review. Even if your doctor prescibes “medically necessary” skilled nursing care for you in a skilled nursing facility and continues to certifiy that your condition has not stabilizied, this does not guarante that Medicare will provide nursing facility coverage. The doctor’s opinion must be approved by both the nursing facility’s utilization review comittee- facility doctors who review partient conditions -and by the Medicare “intermediary”.

How Much Medicare Pays:

  • During the first 100 days of coverage, Medicare pays for these amounts for skilled nursing facility care:
  • Days 1 to 20. You are responsible for paying up to your Medicare Part A deductible, if you have not already reached it. once you have paid the deductible, Medicare pays all your covered nursing facility charges for the first 20 days.
  • Days 21 to 100. After the first 20 days of coverage, Medicare pays all covered charges except what is called a “coinsurance” amount, for which you are personally responsible. In 2016, coinsurance amount was $161 per day; the figure goes up each year.
  • Days 101 on. After 100 days in a skilled nursing facility, you are on your own. Medicare pays nothing toward your stay there.
Last Updated On August 13, 2018