If you are a senior 65 or older, then you probably have Medicare. Understanding your Medicare coverage can be very important, especially if you find yourself in the hospital, or needing care after a hospitalization. Medicare Part A covers Medicare inpatient care, including care received while in a hospital, a skilled nursing facility, and, in limited circumstances, at home.
If you spend more than three consecutive nights as an inpatient in a hospital, and it is determined that you need continued skilled care for treatment of the condition for which you are receiving hospital services, Medicare will cover 100% of the costs for the first 20 days of care in Medicare-certified skilled nursing facility. After 20 days, there is a copayment due. (The copayment for 2018 is $167.50.) The copayment can be covered by a secondary or Medigap policy, Medicaid, or privately, out of pocket.
It is very important to note that Medicare will only cover your stay if you have actually been in the hospital on an “admitted’ status for three consecutive nights. Due to increasing healthcare costs many hospitals have been “observing” patients as “outpatients” before admitting them as “inpatients.” The three-day count does not begin until the patient is designated as “admitted inpatient.” This whole process can end up being invisible to you and can impact your ability to receive inpatient rehabilitation care. This is because from Medicare’s perspective, you were not actually admitted to the hospital and have not met the three-night requirement for coverage in a skilled nursing facility.
Many people are unaware of this rule, and do not know their “admit status” in the hospital. It is your right as a patient to know what is going on. If you think you will be unable to return home safely after your hospitalization or will need re- habilitation care, address your concern with your physician. Following a qualifying hospital stay, a beneficiary must enter the skilled nursing facility within 30 days of hospital discharge to qualify for Medicare coverage.
Admission to a skilled nursing facility under a Medicare stay requires a physician’s order and the need for skilled care. Skilled care is defined as care that requires the skills and oversight of a professional such as a registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech-language therapist.
The services that Medicare defines as skilled are:
- Intravenous or intramuscular injections and intravenous feeding
- Enteral feeding (i.e., “tube feedings”) that comprises at least 26 per cent of daily calorie requirements and provides at least 501 milliliters of fluid per day
- Nasopharyngeal and tracheostomy aspiration
- Application of dressings involving prescription medications and aseptic techniques for extensive wound care
- Treatment of extensive decubitus ulcers or other widespread skin disorder
- Rehabilitation nursing procedures, including the related patient education regarding management and adaptive as- pects of nursing that are part of active treatment, e.g., the institution and supervision of bowel and bladder training program
- Inpatient level physical, occupational or speech therapy
There is a maximum of 100 days of stay per benefit period. The benefit period ends when the beneficiary has not re- ceived any inpatient hospital or skilled nursing care for 60 consecutive days. There is no limit to the number of benefit periods available. If a beneficiary leaves the skilled nursing facility for less than 30 days and then needs to return for the same medical condition, they will not need another qualifying three-day hospital stay to be eligible to use the coverage left in their benefit period. If the break lasts for 60 consecutive days, then this triggers the end of a benefit period and a new benefit period begins with a new inpatient hospitalization. Although each benefit period has a total benefit of 100 days, a 100-day stay is not expected or guaranteed. Medicare provides no coverage after 100 days. Beneficiaries must pay for any additional days out of pocket or apply for Medicaid coverage. Long-term care insurance policies are also an option for payment after Medicare coverage is exhausted.
Medicare does not cover custodial or non-skilled care. It is important to understand that Medicare is not intended to cover long-term care services. Medicare covers only short-term stays in Medicare-certified skilled nursing facilities. These temporary stays are typically meant to be part of their recovery from a serious illness, injury or operation.
A medical situation that requires temporary care in a skilled nursing facility often leads to the realization that you can no longer be home and that long-term care is necessary. Since Medicare coverage is only offered for a limited time, families are often upset when they receive notice that their loved ones must either pay for ongoing care privately, apply for Medicaid or be discharged. The confusion comes from a misunderstanding of Medicare’s definition of skilled care. A skilled nursing facility is not looking to discharge anyone who qualifies for the Medicare benefit; however, once coverage is no longer available other resources must be explored.
Key Points
- A Medicare-covered stay in a skilled nursing facility requires a three-consecutive-night inpatient hospitalization.
- Each benefit period has 100 days of skilled nursing days available. A 60-day period with no impatient stay is necessary to reset the benefit period.
- The first 20 days are covered bu Medicare at 100%, a co-pay is due after day 20.
- There must be a skilled need as defined by Medicare.
- A 100-day is not guaranteed or expected.
- Medicare does not cover long-term custodial care.
Caring Connections of New Jersey and Pennsylvania is a non-profit organization whose primary mission is to educate seniors in their own communities on the services available to them as they age and to provide education and support to the families who are caring for their aging loved ones. Our vetted speaker’s bureau has a variety of topics fit for audiences over 55 years old and bring the speakers TO YOU in your community. Whether it’s community services that are of no cost to a senior or the full scope of care, we can assist with whatever resource you may need. Please visit www.caringconnectionsnj.org for more information.