Medicare and Nursing Homes

MEDICARE’S LIMITED NURSING HOME COVERAGE FOR 2018

Medicare Part A covers institutional care in skilled nursing facilities on a very limited basis.

The following criteria must be met before there is Medicare coverage for a stay in a skilled nursing facility.

  1. The Medicare recipient must enter the nursing home no more than 30 days after being admitted to the hospital on an in-patient basis. (Beware — being admitted to the hospital under “in-patient basis” qualifies for the limited nursing home coverage under Medicaid part A. If you are admitted under “observation status” there is no Medicare coverage no matter how long the hospital stay)
  2. If the Medicare recipient is admitted to the hospital on an in-patient basis, the hospital stay must have been for at least 3 days. In calculating the number of days do not count the day of discharge.
  3. The Medicare recipient’s treating physician must order a skilled level of care in the nursing home facility. A skilled level of care is care that cannot be provided at home or on an outpatient basis that is delivered by or under the supervision of a professional such as a physical therapist, registered nurse of licensed practical nurse on a daily basis.
  4. As soon as the nursing facility or medical provider determines that the Medicare recipient no longer needs a skilled level of care, the Medicare coverage ends.

If the criteria outlined above is met Medicare Part A covers up to 100 days of “skilled nursing” care per spell of illness. However co-payments may apply.

  1. Beginning on day 21 there is a significant co-payment equal to one-eighth of the initial hospital deductible ($167.50 per day for 21-100 days of each benefit period).
    1. If you have a Medi-gap insurance policy this co-payment may be covered by the policy. The Medicare Recipient should check his policy or contact his insurance agent.

If the Medicare Recipient has exhausted his Medicare Part A benefits for skilled nursing home coverage or does not meet the criteria needed for Medicare Part A benefits, it is time to consider whether the recipient qualifies for coverage under Florida’s Institutional Care program AKA Medicaid.