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Traditional nursing homes are facilities that provide long-term custodial care to people who cannot be cared for comfortably and/or easily at home. This can be due to physical, emotional, or mental problems. Assistance often includes help with bathing, dressing, eating, using the bathroom, and other daily activities. Payment for these types of nursing homes is not included in Medicare coverage.
What Does Medicare Cover?
Medicare coverage only includes care in nursing homes under certain limited circumstances. For nursing home care to be covered under Medicare policies, the care must be considered medically necessary, for a limited period of time, provided by a Medicare certified skilled nursing facility, and immediately after a qualifying inpatient hospital stay of at least three days. Skilled nursing care is designed to help improve or maintain your condition, and/or to set up a maintenance program designed to maintain your condition and keep you from getting worse after a hospital stay. For the skilled nursing or rehabilitative care to be covered, your doctor must order the skilled care and specify that you require the skilled care on a daily basis as an inpatient.
What is a Skilled Nursing Facility?
While skilled nursing facilities may be part of a nursing home or hospital, these facilities are not traditional nursing homes. They provide skilled health care designed to help manage, observe, and evaluate your medical needs after a hospitalization. The care is available only for a short time and includes services like physical therapy and/or intravenous injections. For Medicare coverage to apply, the facility must obtain a certification from Medicare that states the facility has the skilled care and rehabilitation services necessary to be considered a skilled nursing facility.
What Is the Difference Between Skilled Nursing Care and Traditional Nursing Home Care?
Skilled nursing care is short-term care designed to improve or maintain your condition. It is care provided by skilled professionals—nursing or rehabilitative care provided by non-skilled professionals is not covered by Medicare. While skilled nursing care may be provided on a daily inpatient basis, skilled nursing care is not meant to assist you with things you can do on your own, such as monitoring insulin levels for diabetes, bathing, or dressing yourself. Traditional nursing home care is a kind of long-term assisted living arrangement under which custodial care is provided even when no medical treatment is necessary. Often times, people require long-term care in nursing homes when they are nearly or completely incapable of taking care of themselves on a daily basis. If you need additional help identifying what kind of care you need, talk to your doctor or visit www.Medicare.gov.
How Much Does Medicare Pay?
Original Medicare will pay the full cost of up to 20 days of care for covered services provided by a skilled nursing facility. If you qualify for skilled nursing care, your Medicare coverage will include a semi-private room, meals, medications, medical supplies, dietary counseling, and the required skilled nursing and/or rehabilitative care. For days 21 through 100, Medicare coverage will pay for all of the services except for a daily copayment, which you will be required to pay. In 2008, the copayment was $128 per day. This copayment may be significantly cheaper under a Medicare Part C plan. After the 100th day, Medicare coverage no longer applies and you will be required to pay the full cost of the services. These timelines and benefits may be different under certain types of Medicare policies, such as Medigap or Medicare Part C (also known as a Medicare Advantage Plan). Check with your plan for details.
What About Medicare Part C – Will It Pay for Nursing Home Care?
Most Medicare Part C plans, also known as Medicare Advantage Plans, provide Medicare coverage for skilled nursing facility care if the care is medically necessary. Costs and benefits may be different under different Medicare policies, including between Medicare Part C plans and Original Medicare plans. Like Original Medicare, most of these plans will not cover custodial care in nursing homes if it is the only type of care you need. However, there may be some that offer additional benefits or services. For more information, compare Medicare Advantage Plans online or contact your Medicare Part C plan provider directly.
Can I Get Help Paying for Nursing Homes Somewhere Else?
Even though Medicare does not pay for traditional nursing homes, there are places you can go to for help with nursing home costs. You can pay for nursing homes that provide custodial care with Medicaid, personal savings, a managed care plan, Medigap policies, and long-term care insurance. However, nursing homes must be under contract with a managed care plan in order for the plan to cover care. Medigap policies will only provide Medicare coverage for skilled nursing care that is covered under regular Medicare policies. This means that Medigap policies likely will not cover long-term custodial care. Long-term care insurance policies are viable options to pay for nursing homes as long as you can afford the coverage. Payment help may be available if you need long-term care and you have little income and limited resources. Contact your state department to find out more. For a free guide to choosing a long-term care insurance policy, contact the National Association of Insurance Commissioners (NAIC) or call 1-800-MEDICARE and ask for the Guide to Health Insurance for People with Medicare.
For additional questions concerning Medicare coverage of skilled nursing homes, contact your Medicare Fiscal Intermediary or your State Health Insurance Assistance Program (SHIP). You may also visit www.medicare.gov to compare certified skilled nursing facilities in your area.