2009-08-14 / Columnists

Spo tlight On Elderlaw

Medicare's Limited Nursing Home Coverage
Commentary By Nancy J. Brady, RN, Esq. And Linda Faith Marshak, Esq.

Medicare is health coverage provided by the federal government to individuals who are over age 65, and other individuals who qualify because they have been disabled for at least two years. Many people mistakenly believe that their Medicare will cover the cost of all nursing home stays. In fact Medicare's coverage of nursing home care is quite limited. Medicare covers only up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered. The result of these requirements is that Medicare coverage often ends even before the maximum of 100 days, resulting in Medicare recipients often being discharged from a nursing home before they are ready, or having to pay for the nursing home care with savings.

In order for a nursing home stay to be covered by Medicare, you must enter a Medicare-approved "skilled nursing facility" or nursing home within 30 days of a qualifying hospital stay. That hospital stay must have been for an acute illness, and must have lasted at least three days. The care in the nursing home must be for the same condition as the hospital stay. In addition, you must need "skilled care." This means a physician must order the treatment and the treatment must be provided daily by a registered nurse, physical therapist, or licensed practical nurse. Finally, Medicare only covers "acute" care as opposed to custodial care. This means it covers care only for people who are likely to recover from the medical conditions, rather than care for people who will need ongoing help with performing everyday activities, such as bathing or dressing (also known as "chronic" or "custodial" care).

Note that if you need skilled nursing care or rehabilitation to restore to your physical status prior to the hospitalization, then the care should be provided by Medicare. In addition, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient's care and status. In such cases, Medicare should continue to provide coverage. Once you are in a facility, Medicare will cover the cost of a semiprivate room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($133.50 per day in 2009). This copayment may be covered by a Medigap policy, or secondary insurance. After 100 days are up, you are responsible for all costs. If you are in a nursing home and the nursing home believes that Medicare will no longer cover you, it must give you a written notice of non-coverage. The nursing home cannot discharge you until the day after the notice is given. The notice should explain how to file an expedited appeal to a Quality Improvement Organization (IPRO in New York) - a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries. You should appeal right away. You will not be charged while waiting for the decision, but if the decision is ultimately to deny coverage, you will be responsible for the cost. Once Medicare no longer covers the nursing home stay, an individual has the choice of going home, or financing continued care in the nursing home through other means.

Please look for our upcoming columns regarding eligibility for Medical Assistance Benefits for nursing home care, and advance planning for asset protection.

The attorneys are available for consultation for these and other matters. Please contact our office at 718-945- 7777.

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