Does medicare pay for nursing home after hospital stay

The thought of paying for a nursing home stay can feel frightening. Many people begin to question if or how long Medicare will pay for a nursing home stay? While Medicare isn't designed for nursing home stays, it can be covered if you meet a few different requirements.

Table of Contents Show

How Many Days Will Medicare Pay for a Nursing Home Stay?
100 Days of Medicare Per Illness
Medicare Coverage in the First 20 Days
Medicare Coverage After the First 20 Days
Notice of Non-Coverage and Appeals
Medicare Nursing Home Eligibility Requirements
Nursing Home Care Eligible for Medicare
Medicare's Nursing Home Coverage Has Stringent Requirements

How Many Days Will Medicare Pay for a Nursing Home Stay?

Medicare is a health insurance program available to Social Security recipients who are 65-years-old or older, people who are disabled, those experiencing stage four renal failure, or people who have received Social Security Disability Benefits for the previous 25 months or longer. Medicare should not be confused with Medicaid, which is a State and Federal program available for people who have limited income and assets.

100 Days of Medicare Per Illness

For those wondering, "How long will Medicare pay for a nursing home stay?" the truth is that, typically, Medicare doesn't pay for long-term care. It is designed to help cover the costs for skilled nursing care needed following a hospital stay and coverage includes up to 100 days of services per illness. "Skilled care" in this sense means nursing or rehabilitation services performed by professionals who are able to manage and evaluate the patient's care and needs. Long-term stays in nursing homes fall under a different category and are not included in Medicare plans.

Medicare Coverage in the First 20 Days

Once a Medicare participant is enrolled in a Medicare-approved facility, Medicare covers the following costs for 20 days:

Semi-private room
Meals
Skilled nursing and rehabilitative services
Necessary medical supplies

Medicare Coverage After the First 20 Days

After the first 20 days, Medicare participants will be responsible for a daily copay amount of $170.50 (2019) for the remaining 80 days of the 100 day stay. After day 100, the Medicare participant is responsible for 100 percent of costs. If Medicare is no longer paying and the patient cannot afford to pay, the nursing home will issue a written notice of non-coverage. Once the notice is issued, the nursing home can discharge the patient the following day.

Notice of Non-Coverage and Appeals

The notice of non-coverage should include an explanation of how to file an expedited appeal to QIO (Quality Improvement Organization). The sooner the appeal is made, the better. While the appeal is being considered, care continues at no cost, but if the QIO denies coverage, the Medicare participant will be responsible for costs incurred in the interim. If the QIO denies coverage, a further legal step would be to appeal to an Administrative Law Judge with the help of a lawyer.

Medicare Nursing Home Eligibility Requirements

In order to be eligible for nursing home care with all or some services paid for by Medicare, first a person must qualify to receive the benefits. Qualification includes a hospital stay of at least three days under the care of a Medicare-certified nursing staff. This hospital stay must take place 30 days (or fewer) before moving to the nursing home. Secondly, the nursing home you choose must be Medicare and Medicaid-certified for Medicare to pay. To find a Medicare and Medicaid-certified facility visit Medicare.gov.

Nursing Home Care Eligible for Medicare

The main points to be aware of are that to be eligible for a nursing home stay covered by Medicare, the following requirements must be met:

The nursing home must be Medicare approved
Medicare participant must enter the nursing home within 30 days of a hospital stay of three days or longer.
Medicare participant must require skilled care.
Required treatment must be ordered by a physician and performed by an LPN, RN or physical therapist.
In general, Medicare covers acute care, but it does not pay for services needed to help with everyday activities like getting dressed or bathing.

Medicare's Nursing Home Coverage Has Stringent Requirements

These requirements that patients must meet in order for Medicare to cover nursing home stays are fairly stringent, and the most important thing to remember is that even if these requirements are met, Medicare will only pay for a limited period. For this reason, it is important to consider other alternatives for payment long before nursing home care may be required.

Medicare Part A Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older and individuals under age 65 who have been disabled for at least 24 months who meet the following 5 requirements: 1) the resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) the resident was hospitalized for at least 3 consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) the resident was admitted to the facility within 30 days after leaving the hospital; 4) the resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) a medical professional certifies that the resident requires skilled nursing care on a daily basis.

Where these five criteria are met, Medicare will provide coverage of up to 100 days of care in a skilled nursing facility as follows: the first 20 days are fully paid for, and the next 80 days (days 21 through 100) are paid for by Medicare subject to a daily coinsurance amount for which the resident is responsible.

But beware: not everyone receives 100 days of Medicare coverage in a skilled nursing facility. Coverage will end within the 100 days if the resident stops making progress in their rehabilitation (i.e. they “plateau”) and/or if rehabilitation will not help the resident maintain their skill level. Coverage will also be terminated if the resident refuses to participate in rehabilitation.

Written notice of this cut-off must be provided. When Medicare coverage is ending because it is no longer medically necessary or the care is considered custodial care, the health care facility must provide written notice on a form called “Notice of Medicare Non-Coverage” to the resident and their designated representative. If you believe rehabilitation and Medicare coverage is ending too soon, you can request an appeal. Information on how to request this appeal is included in the Notice of Medicare Non-Coverage.

Don’t be caught off-guard by assuming your loved one will receive the full 100 days of Medicare. Be sure to have a plan in place to preserve assets while securing government benefits to help pay for long-term health care needs.