Medicare and Nursing Homes What You Need to Know

If you are 65 or older, or have a certain disability, then you may qualify for Medicare. The rules on paying for nursing home care, though, are different and require that you follow strict guidelines and are in need of certain care in a skilled nursing facility (SNF). Medicare does not pay for room and board at a long term facility but can be used for medical visits or hospital care and certain supplies.

Medicare only pays for a portion of the skilled services you need and for a limited time. To be eligible, you will need to meet the following criteria:

  1. 1. You recently stayed at a hospital for at least 3 days
  2. 2. You must have been admitted to an approved nursing facility within 30 days of the recent hospital stay
  3. 3. Your doctor has certified that you need certain skilled care such as physical therapy or hospice care

Skilled services include occupational therapy and speech-language pathology and medical supplies such as wheelchairs, beds, walkers, oxygen and walkers.

You can receive up to 100 days of skilled nursing care for each episode of illness or until the care ends. Skilled care refers to that which has been prescribed and can only be provided by a nurse. It is care that can only be provided at an SNF.

Be aware that the total cost of the care ends at day 20. Afterwards, you must meet a copayment of up to one-eighth of the initial hospital deductible or $157.50 per day as of 2015.

Once the 100 days expires or the skilled care ends sooner, you may remain in the SNF but are ineligible for Medicare assistance so long as you have not received skilled care for at least 60 days.

Using Your Assets First

If married, your spouse can protect a certain amount of assets that need not be reduced to make you eligible for these costs before Medicare steps in.  Transferring assets at less than market value will render you ineligible for a certain time unless it concerned a disabled child or a spouse.

Appeal of Non-Coverage Notice

If an SNF sends a Non-Coverage notice because it feels the resident no longer needs skilled care, there are steps you can take to challenge it. Request that the facility send the bill to Medicare where the resident’s medical records will also be submitted for Medicare for review by a fiscal intermediary to see if the facility’s determination was incorrect or unsupported by the records.

During the review, the resident is not obligated to pay for costs, though it will be retroactive if the appeal is denied. If denied, you can appeal to an ALJ, or Administrative Law Judge. The next level is to an Appeals Council in Washington and then to federal court.

Consult Elder Attorney Patricia Bloom-McDonald

For over 25 years, Patricia Bloom-McDonald has been a legal advocate for elders and their families for estate planning, nursing home and Medicare issues. Call her office today to schedule an appointment about your or a loved one’s issues with Medicare and nursing home living.