Medicare Part A will pay for part of up to 100 days of skilled nursing care per spell of illness in a nursing home or inpatient rehabilitation center. In addition to meeting the basic eligibility requirements for Medicare detailed in the earlier posts in this series, there are three other requirements that must be met in order to receive this nursing home coverage under Medicare:
- The person needing care must enter the nursing home within 30 days after an inpatient hospital admission that lasted at least three days, not counting the day of discharge. Note that admission for “observation status” does not currently meet Medicare's definition of a hospital admission.
- The care that will be provided in the nursing home/rehab center must be for the same condition that caused the hospitalization. For instance, if an older person has knee replacement surgery in the hospital and then is discharged to a rehabilitation center within a nursing home for physical therapy, that would meet this requirement.
- The person must need a certain type of “skilled care” that cannot be provided at home or on an outpatient basis, such as physical, occupational, or speech therapy. In addition, the care must be provided on a daily basis and be ordered by a doctor and delivered by, or under the supervision of, professionals such as a registered nurse or physical therapist.
The need for physical therapy after a hospitalization is the most common reason older people are discharged to a nursing home for skilled care. This usually occurs after a stroke, a fall resulting in a broken bone, or hip and knee replacement surgeries.
People often do not get the full 100 days of skilled nursing coverage for a couple of reasons.
First, some elderly people need custodial nursing home care, not skilled care. This group tends to include people with advanced dementia or Alzheimer's disease and the frail elderly. When someone needs assistance with the activities of daily living, then it is just considered custodial nursing care, not skilled care. Such activities of daily living include stand-by assistance while walking, transferring, getting dressed, bathing, help in the bathroom, medication management, food preparation and/or assistance in eating, and the need to live in a 24-hour protective environment where someone is available to immediately respond for help. Medicare Part A does not pay forany custodial nursing home care.
Second, when an older person does qualify for skilled care, facilities sometimes end Medicare coverage for this care before they should. The reason for this is a belief amongst some skilled nursing professionals that if a patient has stopped making progress or has “plateaued,” then Medicare coverage should end, even if all 100 days of coverage have not been used.
The result is that some people who are discharged to a nursing home or rehab. center after a hospital stay may get no Medicare Part A coverage, may just get a few days or a couple of weeks, or they may get the full 100 days of coverage. It will depend upon each person's health situation and the practices of the facility they are in. Some facilities are more likely to continue therapy and qualifying care for the full 100 days.
It should be noted that as soon as the facility determines that a resident no longer qualifies for skilled care, then Medicare coverage will end. Also, even if someone does continue to need skilled care, if they have used all 100 days, Medicare Part A coverage will end. In that case, additional skilled care will have to be paid for with the person's income and savings and/or long-term care insurance. As an elder law attorney who assists people with Medicaid qualification in Michigan, this is often when families first call me to help them determine how they will pay for long-term custodial nursing home care, which often costs in excess of $200 per day.
In any case, there is also the issue of copayments. Medicare Part A actually only pays for all of up to the first 20 days. Beginning on day 21 of the nursing/rehab. facility stay, there is a $144.50 per day copay that the individual will be responsible for. Frequently, this copay will be covered by the person's supplemental health insurance policy (“Medigap” insurance). It should be noted that such supplemental health insurance policies do not pay for custodial nursing home care.
A new spell of illness can begin, resulting in an additional 100 days of Medicare coverage, if the person has not received skilled care in a nursing/rehab facility or hospital for a period of 60 days. For example, if an elderly person falls and breaks their hip, resulting in a need for skilled rehab in a nursing facility, that would be one spell of illness. If, two years later, they have a stroke and need skilled care for again, that would be considered another qualifying spell of illness since more than 60 days passed.
This new spell of illness provision does not work to help pay for long-term custodial nursing home care, because the elder must still meet the definition of needing skilled care.
When a person is discharged from the hospital to a nursing home/rehab. center that provides Medicare coverage, that facility must give the patient a written notice of whether the facility believes the person requires skilled care that falls within Medicare's coverage.
In my next post, I will discuss requesting a review of a facility's decision then the patient no longer meets Medicare's requirements in order to receive skilled care coverage.