Medicare Coverage of Nursing Home Care

Many people confuse Medicaid and Medicare. This article addresses when Medicare covers nursing home expenses, and when it does not.

Generally, to qualify for Medicare, one must be 65 years old, or, if under 65, have a disability.

Medicare consists of several “Parts.”  Part A, also known as Hospital Insurance, covers inpatient care in a hospital or skilled nursing facility (but not custodial or long-term care), hospice care, home health care, and inpatient care in a religious nonmedical health care institution.

In order for Medicare to cover nursing home expenses, one must satisfy the following conditions:

  1. 3 days: have had a minimum 3 days of inpatient hospital stay for a medically necessary illness or injury. The 3-day count includes the day of admission, but not the day of discharge; also, the skilled nursing or rehabilitation services must be related to the medically necessary hospital stay.
  2. 30 days: gain admission to a nursing home within 30 days after the date of discharge for purpose of either improving or maintaining one’s current condition;
  3. Skilled nursing required: require skilled nursing or rehabilitation services; and
  4. Doctor certification: provide an order from a physician that skilled nursing re rehabilitation services are required.

Once a person qualifies as above, Medicare pays for all of the costs of the first 20 days, all but $167.50 per day (as of 2018, reset annually) for days 21-100, and nothing after 100 days.

In the event one’s condition improves and is absent from the skilled nursing facility for less than 60 days, meaning one is still in their initial benefit period, the 3-day minimum hospital stay is not required, and one’s coverage picks up where it left off; otherwise, the initial requirements must set forth above must be met, at which time a new 100-day coverage period begins.

Posted in Medicare

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