Medicare’s Limited Nursing Home Coverage

Many people believe that Medicare covers nursing home stays. In fact, Medicare’s coverage of nursing home care is quite limited. Medicare covers 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 recipients are often discharged from a nursing home before they are ready.

In order for a nursing home stay to be covered by Medicare, you have to meet the following requirements:

  • You must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; “observation status” does not count) that itself lasted for at least three days (not counting the day of discharge). Note: This requirement may be waived under the current special rules in effect in Michigan due to Covid.
  • The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
  • You must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered “skilled,” nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse, or licensed practical nurse. 
  • Medicare only covers “acute” care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing. 

Note that if you need skilled nursing care to maintain your status (or to slow deterioration), then the care should be provided and is covered 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.

When you leave a hospital and move to a nursing home that provides Medicare coverage, the nursing home must give you written notice of whether the nursing home believes that you require a skilled level of care and thus merit Medicare coverage. Once you are in a facility, Medicare will cover the cost of a semi-private 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 ($194.50 a day in 2022). This copayment may be covered by a Medigap (supplemental) policy. 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 (QIO). A QIO is 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 QIO denies coverage, you will be responsible for the cost. If the QIO denies coverage, you can appeal the decision to an Administrative Law Judge (ALJ). It is recommended that a patient hire a lawyer to pursue an appeal.  For an article from the Center for Medicare Advocacy on nursing home discharges, click here.

You cannot rely on Medicare to pay for your ongoing long-term care. Medicaid is the program which covers long-term care for those who qualify. Contact us to schedule a consultation to create a Long-Term Care Plan. We will assist you in reviewing your options and developing a plan to pay for long-term care on an ongoing basis. Often, clients can be qualified so that they will receive Medicaid benefits once Medicare coverage ends. We strongly recommend that you contact us as soon as you know you or a loved one is entering a nursing home. We can often assist during the period of time covered by Medicare in order to plan for a transition to Medicaid eligibility as quickly as possible.

For more information on Medicare, click here.

If you have specific questions about your situation or would like to learn more, reach out to the team at WBH here.

Read more articles:

Medicaid’s “Snapshot” Date and Its Crucial Impact on a Couple’s Financial Picture

When a married couple applies for Medicaid, the Medicaid agency must analyze the couple’s income and assets as of a particular date to determine eligibility. The date that the agency chooses for this analysis is called the “snapshot” date and it can have a major...

What Are the Drawbacks of Naming Beneficiaries?

Although in many situations the advantages outweigh the disadvantages when selecting beneficiaries, there are always exceptions. What Is a Beneficiary? Beneficiaries are individuals who you select to receive money, various other assets, or specific bequests (such as...

Estate Planning: An At-a-Glance Overview

Estate planning, or legacy planning, entails preparing your affairs for the future, including death and other life events. While older adults might give more thought to estate planning, it is an essential tool at any age. Why It’s Important With estate planning,...

Claiming Social Security Benefits at Age 70

If you are about to turn 70, congratulations on reaching a big milestone.  And if you also have delayed claiming Social Security retirement benefits up till now, you are joining a select group -- only 6.5 percent of Social Security recipients put off collecting their...

Step-Up in Basis and Why It Matters in Estate Planning

Recent news stories may have made you aware of the “step-up in basis” and the current administration’s desire to eliminate or adjust it. If you are considering engaging in estate planning or you may be inheriting assets, it is important to understand what the step-up...

The 6 Biggest Estate Planning Mistakes

If you’re like most people, you have the best of intentions regarding how you want your estate distributed when you die or your affairs handled should you become incapacitated. Unfortunately, without proper planning, your best intentions may not be enough. Here are...

Is a Medicaid Planner Right for You?

Medicaid Planner is a term that encompasses many different types of professionals who may be able to assist you or a loved one with qualifying for Medicaid benefits. Not every Medicaid Planner may be appropriate for your individual needs or situation. Although...

Estate Planning for Surviving Spouses

After losing a spouse or longtime partner, it’s difficult to look past your grief. However, it’s crucial to understand the important and timely decisions you must make regarding your finances and personal estate plan. Estate planning is an ongoing process, as it...

Don’t Wait Until You’re Sick to Create an Estate Plan

In the wake of the pandemic, rising inflation, mass shooting tragedies, and other events, more people recognize that they need to plan for the future. Yet while financial planning has been at the top of many Americans’ minds, a vast majority of people have stalled in...

Becoming a Family Caregiver for an Ailing Loved One

Taking on the responsibility of providing full-time care for an aging or disabled loved one can be a rewarding experience. Being a primary caregiver helps you rest assured that your loved one is receiving compassionate care from someone who will go above and beyond to...