YES, Medicare and Medicaid are very different programs. Medicare is an entitlement program and has limited nursing home benefits. Medicaid is a "means tested" program that, once qualified, will pay the vast bulk of nursing home cost. However, Medicare is a crucial part of the healthcare network for the elderly. It is important to understand how Medicare and Medicaid overlap and interrelate for nursing home care.
Medicare is complex in its entirety, but the basics as it relates to nursing home care, is quickly understandable.
By reading below much confusion can be avoided when a loved one enters a Nursing Home.
Common Questions are:
What does Medicare cover in a Skilled Nursing Facility?
Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a skilled nursing facility (SNF) under certain conditions for a limited time.
Medicare-covered services include, but aren't limited to:
- Semi-private room (a room you share with other patients)
- 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 SNF
*Medicare covers these services if they're needed to meet your health goal.
If you're in a SNF, there may be situations where you need to be readmitted to the hospital. If this happens, there's no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there's a cost to hold the bed for you.
To QUALIFY, the following criteria MUST BE MET:
People with Medicare are covered if they meet all of these conditions:
- You have Part A and have days left in your benefit period.
- You have a qualifying hospital stay.
- Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.
- You get these skilled services in a SNF that's certified by Medicare.
- The Nursing Home stay occurred within 30 days of the discharge from the hospital.
- If the patient was previously on Medicare coverage for a Nursing Home stay of 100 days, the patient MUST have been back at home for a minimum of 60 days to qualify for another stay covered by Medicare.
- You need these skilled services for a medical condition that was either:
- A hospital-related medical condition.
- A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you're getting observation services in the hospital, you're considered an outpatient—you can't count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you're an inpatient or an outpatient.
- If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
- If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
It is important to point out that 100 days of Medicare coverage IS NOT GUARANTEED! Coverage can end at ANY TIME if the patient is deemed to have "plateaued" in rehabilitation without a reasonable expectation for improvement.
Here are some common hospital situations that may affect your SNF coverage:
||Is my SNF stay covered?
||You came to the Emergency Department (ED) and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day.
||Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.
||You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days.
||No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.
Remember, any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.
How long will Medicare pay for Nursing Home Care?
When the above criteria are met, Medicare will pay up to 100 days of care at the following percentages:
- 100% of the rehab bill for the first 20 days if the patient continues to show the potential for improvement related to the rehab.
- 80% of the rehab bill days 21 - 100 if the patient continues to show the potential for improvement related to the rehab. If the patient DOES NOT have a secondary health insurance plan, the patient will be responsible for the remaining 20% as a co-payment ($164.50 per day) unless qualified for Medicaid and even then will be required to pay the Patient Responsibility portion required by Medicaid.
Finally, many seniors enter the Nursing Home enrolled in Medicare Replacement Plans; typically HMOs. These plans are issued by either private or publicly traded companies. While these plans can be very helpful in reducing a senior's health care coverage premiums in the community, they can be very aggressive in the determination of when rehabilitation coverage will end. The goal is cost reduction by limiting the number of days of coverage. For this reason, many Nursing Homes will suggest that the patient dis-enroll from these HMOs and re-enroll in Medicare Part A. In most instances, Medicare Part A will allow the patient to retain rehabilitative coverage longer than Medicare Replacement Plans. Please consult with your Medicaid Attorney to find out if it is in YOUR loved one's best interest, not the Nursing Home's or the HMO's best interest, BEFORE making ANY changes to your Medicare/Medicare Replacement Plan coverage.
If the determination is made that Long Term Care is necessary after the rehabilitative care has ended, monthly Long Term Care costs will range from approximately $8,000 to $10,000.00+ per month in the state of Florida. $100,000.00 or more per year. One of the first questions asked by the Nursing Facility will be: "Who will pay the $8,000 to $10,000.00 per month?"
There are only 3 sources for payment!
- Privately paying from personal assets and income.
- Long Term Care insurance if purchased prior to the need.
- Florida Long Term Care Nursing Home Benefits (Medicaid Institutional Care Program)
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