Nursing Homes and Medicare

Why nursing homes?

A nursing home is a place for people who don't need to be in a hospital but can't get the required health care at home. Most nursing homes have skilled nurses and nursing aides 24 hours a day. Some nursing homes function like hospitals, with nurses' stations on each floor, and in addition to medical care, some provide physical, speech and occupational therapy. Other nursing homes look more like home, where there is no fixed day-to-day schedule. Residents may have open kitchens and interact with neighbors, and the staff is encouraged to develop relationships with residents. Some nursing homes have special care units for people with serious memory problems, such as Alzheimer's disease. Some will let couples live together. Nursing homes are not only for the elderly, but also for anyone who requires 24-hour care.

According to the U.S. Census Bureau, more than 17,000 nursing homes in the United States care for about 1.6 million people. By 2050 the number of nursing home residents is expected to quadruple to 6.6 million.

Skilled nursing care vs. custodial care

It is important for Medicare beneficiaries to understand the difference between skilled nursing care and custodial care. Skilled nursing care is when you need a nurse or rehabilitation specialist to manage, observe and evaluate your care. Skilled nursing facilities can be part of nursing homes or hospitals. Custodial care helps you with such daily activities as dressing, eating and bathing. Original Medicare covers the costs for skilled nursing care, including the skilled nursing care provided in nursing homes. Medicare does not cover custodial care if it is the only kind of care you need.

Conditions for obtaining Medicare coverage of a nursing home

In order for Medicare to cover the costs of nursing homes, you must meet the following conditions:

• You have Medicare Part A (hospital insurance), with days of nursing home coverage left in your benefit period. You get 100 days of nursing home coverage per benefit period.
• You have an inpatient stay of three consecutive days or more (a "qualifying stay"), counting the day of inpatient admission to the hospital, but not the day of discharge, before being admitted to the nursing home.
• The nursing home is certified by Medicare.
• You begin getting care in the nursing home within a short time (generally, 30 days) after discharge from the qualifying three-day hospital stay.
• Your doctor has ordered the services you need for nursing home care. These services must: require the skills of professional personnel; be needed on a daily basis; be a type of care that can be provided only in a nursing home on an inpatient basis; be needed for a "hospital-related condition" that was treated during the qualifying three-day hospital stay; be needed for a condition that arose in the nursing home while you were being treated there for a hospital-related condition; or be reasonable and necessary for the diagnosis or treatment of your condition.

Nursing home services covered by Medicare

Medicare covers semi-private room, meals, skilled nursing care, physical and occupational therapy, speech-language pathology services, medical social services, medications, medical supplies and equipment used in the facility, ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren't available at the nursing home and dietary counseling.

Your costs for nursing homes

Medicare pays 100 percent of the first 20 days of a covered nursing home stay. A copayment of $144.50 per day (in 2012) is required for days 21-100 if Medicare approves your stay. For days beyond 100, Medicare beneficiaries are responsible for the full cost of care received in nursing homes.

Other coverage options for nursing homes

If you qualify, due to medical necessity, you may have these other options available to you for the coverage of nursing home care:

• Most Medigap (Medicare supplemental insurance ) plans will help pay for nursing homes, but only when that care is covered by Medicare.
• In general, Medicare Advantage (Medicare Part C) plans or other Medicare health plans do not cover nursing homes unless the nursing homes have a contract with Medicare.
• Medicare Part D (prescription drug coverage) covers prescriptions that are provided by the pharmacies within the nursing homes.
• Some employer group health plans or long-term care insurance helps cover the costs of nursing homes.

Nursing home appeals

Medicare coverage of nursing homes is based on specific criteria of the skilled-level of care needed and the consideration of the individual's needs and abilities. However, patients can appeal if services are denied or stopped too soon. Original Medicare patients can appeal to the Medicare claims processing company for Part A. Whether the nursing home makes the coverage decision, patients have the right to a written notice that explains their appeal rights. It is not unusual for patients to begin receiving skilled care at the beginning of their nursing home stay, with the nursing home deciding later that they no longer qualify for skilled coverage. Written notices are required at that time as well, and the same appeal rights apply.