Medicare Coverage for Nursing Facility

What is a nursing facility?

A nursing facility is a long-term care facility. Nursing facilities provide care for people with illnesses or disabilities that make it hard for them to stay in their own homes. Nursing facilities are not hospitals, but they do provide a room; meals; help with daily activities such as eating, bathing, and dressing; and supervision. Nursing facilities are also called nursing homes or care centers. Because the facility is a home, people who live there are called residents.

Aides provide most of the personal care. Physical, occupational, and speech therapists may also give care.

What is Medicare?

Medicare is a federal government program. It provides healthcare coverage for people 65 and older. It also provides coverage for people of any age who have certain disabilities.

When does Medicare pay for nursing facility care?

If a facility provides wound care or uses tube feedings or IVs, it is called a skilled nursing facility (SNF). Skilled nursing care is provided by medical professionals. This includes nurses, doctors, and physical therapists. Examples of skilled nursing care are injections, tube feeding, and dressings on wounds.

Skilled nursing care is different from custodial care. Custodial care can be done by people who have no medical training. Examples of custodial care are help with eating, bathing, and dressing.

Generally, Medicare Part A pays for care in an SNF when these 5 conditions are met:

• A doctor certifies that you need skilled nursing care
• You need daily care that can be provided only in an SNF. The care must be either given by or provided under the supervision of licensed nurses.
• You were in a hospital at least 3 days in a row before entering the SNF. These 3 days do not count the day you left the hospital.
• You started staying at the SNF within 30 days after you left the hospital.
• The problem that needs care was treated in the hospital or started while you were in the hospital.

Medicare does not pay for custodial care if that is the only care you need.

How long will Medicare pay?

Medicare will pay for care in an SNF for up to 100 days in a benefit period. A benefit period starts when you go into the hospital. It ends when you have not received any hospital care or skilled nursing care for 60 days.

If you go into the hospital for at least 3 days after one benefit period has ended, a new benefit period begins. You can have as many benefit periods as you need.

If you leave the SNF and then go back within 30 days, Medicare will keep paying for services until you have reached the 100 days of coverage.

• Medicare pays 100% of skilled nursing care for the first 20 days.
• For the next 80 days Medicare pays 80% of the cost. You pay 20%.

Medicare does not pay for SNF care after 100 days. If you still need skilled nursing care, you must pay for it yourself. It also does not pay for it before the 100th day if you no longer need it. If you still need custodial care, you pay for it until your medical costs exceed your income. Then Medicaid may pay for custodial care.

An SNF cannot demand a cash deposit before you are admitted unless it is certain that Medicare will not cover you.

Where can I go if I have a concern or complaint about a nursing facility?

Contact the facility's administrator or director of nursing when you have concerns. If your problem is not taken care of, call the local ombudsman. The ombudsman, or “ombuds,” helps people who live in care facilities. Their job is to see that residents' rights are not abused. All states have ombuds programs. The ombudsman visits each facility and tries to get to know the residents so they will call if they have problems. The phone number for the ombuds is posted in each facility.

For further information contact:

Leading Age
Phone: 1-202-783-2242
Web site: http://leadingage.org/

You can also call Medicare at 1-800 MEDICARE (1-800-633-4227). Or visit the Web site at http://www.medicare.gov.