Medicare and Nursing Homes

May 21, 2018     About this blog:  click here

Medicare and Nursing Homes

Many people wonder what, if anything, Medicare will pay towards nursing homes.  It does pay, but only under certain circumstances.

First, let’s distinguish between Short Term stays and Long Term stays in a nursing home.

In general, Short Term stays are no more than a few weeks, and sometimes up to three months.  The key point is that it is TEMPORARY:  After the stay, you go back to your own home.

Long Term stays, on the other hand, are usually PERMANENT – in other words, you are not in shape to continue living in your own home, and you are not expected to go back there.

  1. Short Term Stays:

People who are in a nursing home for a short, temporary stay are usually recovering from an operation or other major treatment in a hospital.

For example, you get an artificial knee in the hospital, and then you go to a nursing home to get physical therapy to get your leg working again so you can walk, sit and stand like normal.  Then, you go home.

Short Term stays are temporary because you are in the process of returning back to regular life, with some kind of medical care such as therapy, or changing dressings while an incision heals.

This is all under a doctor’s orders.  It is considered a form of medical treatment.

The Good News:

Medicare pays for short term stays while you recover.  It pays the FULL COST of the first 20 days, which is more than enough for most instances.

If you have to be in longer than that, then Medicare pays most but not all of the cost from the 21st to the 100th day. You have a co-pay of $167.50 per day.  But beyond 100 days, Medicare pays nothing.

In order for Medicare to pay, the nursing home must be licensed as a Skilled Care Facility (which most all are, but it’s good to check).  And, there must be doctor’s orders for the care you are going to get.

Some Medicare insurance policies (Medicare Supplements and Medicare Advantage) pay part or even all of this $167.50 per day co-pay for you, for days 21 to 100.  Check your policy!

The Bad News:

Medicare has one other condition before it will pay, and it’s a biggie:

You must be going to the nursing home to recover from having been in a hospital overnight for at least three days, as an Admitted In-Patient.    Otherwise, no dice.  Period.

What does that mean?

“In-Patient” status used to be shorthand for staying in a hospital bed overnight.  But, not any longer.

You can stay overnight and yet NOT be admitted as an In-Patient, if the hospital chooses to say that you are in “Observation Status” instead.

That means that you’re too sick to be home, but not sick enough to be admitted as an In-Patient with a clear diagnosis and reason to be treated there.

You could stay overnight for a few days in Observation Status, and then go to a nursing home – and Medicare WON’T pay for it, because you were not an In-Patient for three nights or more.

I expect to have to recover in a nursing home.  What can I do about Observation Status?

Try to find out ahead of time if you will be admitted as an in-patient.  If it’s a major operation, then you will be admitted.

But, you also want to find out:  Will you be an In-Patient for at least three nights?

If the answer to either of these is “no,” then tell your doctor that you need to be an in-patient for three days, in order to get the nursing home stay covered.   That might not work, but it’s sure worth a try.

  1. Long Term Stays:

Long Term stays in a nursing home are for people who aren’t able to live at home and take care of themselves any longer.  They don’t need medical care to improve, but they need help with basic functions.

The word used for it is: “custodial.”  The person just needs help living, but not for recovery and improvement.

The person might get physical therapy on a regular basis, but that’s just to maintain function and coordination – not to get back to normal after an injury or operation.

How does it get paid for?

Medicare does not pay a dime towards it.

Instead, the way most people pay for it is that first, they use up most all of their savings,  Then, they qualify for Medicaid, which will pay for it. That’s the government program for people below the poverty line.  Medicaid in fact pays for most long term nursing home care for most people.

A few people buy Long Term Care insurance policies, which help pay part of the costs.

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