Medicare pays 20 days at 100%, not 21. If there is no other payer source, Medicaid would need to be applied for. Yes, VA and /or SS benefits would be given to the nursing facility as part of the accessed state liability amount, if applied. That depends on the state, and if there is a spouse, or at times, an outside housing they plan on returning to.

After the 21 days Medicare pays 100% then the copay is to be paid. Can the skilled facility take the Veterans or Social Security to pay the copay ?

Days 1 through 20: Medicare pays the full cost for each benefit period.
Days 21 through 100: Medicare pays all but a daily coinsurance. In 2018, the coinsurance is $167.50 per day.
After 100 days: Medicare provides no coverage after 100 days. Beneficiaries must pay for any additional days out of pocket, apply for Medicaid coverage, explore other payment options or risk discharge from the facility.

Medicare generally covers only short-term stays in Medicare-certified skilled nursing facilities, the amount Medicare covers depends on how long they need to stay in the SNF because coverage decreases over time

Not if that is the admitting diagnosis, no. Most psychiatric diagnoses are not covered as you will never improve. If it is a primary diagnosis not related to the actual Alzheimer's, then it is possible for coverage.

Are Alzheimer's patients eligible for SNF?

Thank you for this informative article. My Mom recently fractured her hip and is having severe pain making it through a dialysis session. She is non--weightbearing to the left leg and a "non-surgical" candidate. She also suffered a dislocated finger on her left hand and has a cast. It makes her nearly unable to transfer from bed to commode or do anything much. She even is having trouble eating. Case manager here at the hospital says once she is discharged she will probably only receive a few days in a SNF. That doesn't seem right given that the fractured finger is estimated at healing in 6 weeks and the fractured hip in 2-3 months. She is also on a ton of IV and heavy opiates for pain and she is not quite together mentally to even talk coherently with doctors when they come in the hospital room.

Good to read!

sidetracker - It does not matter how many days are used (unless you have maxed your days) prior to a readmission to a hospital, if you return within 30 days you pick back up where you left off prior to the admission. If you used 21 days in a SNF, admitted to a hospital for 4 days, upon readmission to the SNF you have a potential of 79 SNF days remaining.

You have to be treatment free for 60 days of your last SNF day in order to get the potential of 100 days again. This may not be the case with Medicare Advantage plans.

If you have exceeded the first 21 days stay at a SNF then are readmitted to the hospital for 4 days, then readmitted to SNF, does the initial 21 days of coverage restart again?

To Marlo Sollitto - thank you for this amazing, updated article; especially for the info on debunking Medicare's "Improvement Standard." So glad I found this site!

Thanks bill18 - We did not appeal, I was informed that it was the decision of Medicare. Hmm, perhaps we should have been more direct and forceful. Now, I'm second guessing as they DID practically laugh at me and said "She will not get care there, (in reference to the facility we moved her to) she will be back". Now I'm livid...Thanks for the insight, and to all others here, be proactive. I will add, that Mom is now in a third facility. She has acclimated well. It is THE place everyone in our county wants their parents to be. Her condo has been sold and all seems to be moving smoothly. Bill18, thank you, thank you, thank you for your input!

NCM175 - Did you appeal the facilities decision? It was not Medicare's decision. If you did not, you did not follow through. I work for a nursing home and am well aware that the notice can be issued at any time, and that can be a burden on a family. However, the notice is issued in accordance with Medicare's guidelines, and the appeal info is required on the notice to end skilled services. If it was not, it was not a valid discharge.

Our experience was that Medicare paid "as long as patient was making progress with physical therapy". My 88 year old mother could not navigate learning to use the knee scooter, so as far as Medicare was concerned, she was not making progress with her broken ankle. Which she was "non-weight bearing" as per her doctor. She had been at rehab for 10 days, having had 7 days of PT. We were notified on December 22 that her last day of coverage was December 24. Yes, Christmas Eve. Imagine our distress to find and move her at that time!! Word of caution - be prepared for the unexpected!!! Even their written policy is not dependable.

medicare only cover so much on my mom they wanted us to pay i think over 100.00$ a week over that though dont remember but i said she has medicaid & that covers 100% of everything ...

My father in law was moved from hospital to a skilled nursing facility and medicare would only pay if it was for "rehabilitation" and since that was doubtful, it was not covered and they had to pay "out of pocket." This was a surprise for me, so this article is very helpful.

Care4Mom2 - that must be a special managed Medicaid policy. Standard Medicaid will pay for the hospital, and the stay in the nursing home. I help families apply for Medicaid and explain the rules of my state. You may or may not have been responsible - all depends on the state laws, not what the nursing home wants.

Even if your loved one is on Medicaid, make sure you have a private insurance policy. Mom's Medicaid covered "only skilled nursing". When she went from the nursing home to the hospital, if we had not had the insurance policy, that bill balance would have been paid by us. Try to make sure that the nursing home also takes the insurance coverage so that anything that is not covered by Medicaid in skilled nursing will be by insurance. Mom lived only 6 weeks after being in this system and her insurance company was billed $72,000 of which Medicaid paid most but the insurance company paid more than i expected because of the hospital visit. Afterwards we realized we would have been responsible for the balance as her "guarantors" which the nursing home required even though she was on medicaid. It is VERY complicated to say the least. Try to cover every aspect and asked lots of questions, be prepared to have to research those answers because everyone has a different one!

Mom1946- Medicare covers the first 20 days @ 100%. Beginning with day 21 of the skilled nursing facility stay, they deduct $164.50/day (current rate) from their reimbursement to the facility. This is termed co-ins and is the patient's responsibility if they don't have approved State Medicaid or a private, commercial Medicare supplemental plan. The co-ins rate is set by the federal government each calendar year. As for what the nursing facility is receiving in reimbursement, it is based on the "RUG" score once they enter specific info into the billing module. This reimbursment amount could range from $200/day-$900/day depending on what services are being rendered (and frequency). Please note that whatever the co-ins amt is, is the patient's responsibility for days 21-100.

Mom1946 - Medicare pays based on a Resource Utilization Group (RUG) score that is found by entering specific information into facilities charting program. Most of the time Medicare pays lass than the gross amount billed. Every now and then Medicare will pay more than the gross, minus the coinsurance.

cindykpiper - No, they will not.

that is up to the va an the contract they have with the skilled nursing facility. most that i know of will not pay.

what if you have medicare and and va insurance would va pay after 90 days is up

If my mom has to pay a coinsurance of 164.50 a day for skilled nursing facilities and the charge on an invoice from the skilled facility is 164.50 a day on invoice without medicare coinsurance mentioned what exactly does her medicare actually pay? She has benefit days and it seems in my head that the Medicare plan that she has paid premiums for doesn't pay anything is that correct?

I have to have shoulder replacement in Oct. 2017. since I have no one at home to care for me, how long can I go to a nursing home for and medicare pay for it? Also, will this time count against the time allowed for out patient physical therapy.

After a qualifying hospital stay my dad was discharged to a SNF for 6 weeks of IV therapy. One week after admitting, PT has found that he no longer needs skilled care and coverage will end. If they admitted him for his IV therapy how can he be unskilled 7 days later?

Mother had a stroke in December went into rehab and just used up her 100 days. Had a fall is septic and pneumonia. Will she have any more skilled days?

How many times did you have to use the 60 day restart? How long did she live?

What happens if you are in a skilled nursing facility and January 1, comes along and you are enrolled in a new insurance but in the middle of the 100 days? For instance my father went from a Hmo 2 to a Hmo 1 during his stay in the facility ....and will probably use all 100 days. Do they end the Hmo 2 on December 31, and you pay the days past the 21 day threshold and then go into the new plan and then pay the days leading up to that cap or do you stick with the Hmo 2' s plan throughout the whole 100 days?

You should appeal the decision with help from the facility.

My mother had been skilled for a fall months ago. Since that time she had been home for a couple day and re-hospitalized for a totally different reason. She now has a trach, g-tube, immobile, just starting to make eye contact. Aetna medicare insurance denied her skilled days. They are stating that she is able to feed, dress and transfer on own. These were true after her first rehab stay. She is in a completely different nursing home and the (Aetna) is refusing to consider what the current nursing home is stating. What can I do?