Getting Medicare to Pay for Nursing Home Care

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Within the abundance of information regarding benefits that may or may not be available for patients in a skilled care facility is a mound of confusion and frustration. The Kaiser Family Foundation files share “The recently enacted health reform legislation mandated a number of policy changes, demonstrations, and other initiatives relating to nursing home and hospice care. These provisions demonstrate Congressional recognition that Medicare and Medicaid policies relating to nursing home and hospice care are far from perfect and require modification.” However, knowing requirements, preferences, options and individual facility agreements is a common cause of frustration and difficult to understand. This article shares a basic thought to pursue if your loved one is in a critical state and residing in a skilled nursing facility.

Caregivers: don't let the nursing home business office tell you that Medicare can no longer cover room and board for your loved one because he or she isn't "improving."

The Improvement Standard is not, and never has been, a valid reason for nursing homes to cut off these nursing home days. Medicare's nursing home payment manual makes it clear that "[e]ven in situations where no improvement is expected, skilled care may nevertheless be needed." This manual was published in 2014, but some nursing homes haven't adapted to help chronic patients get access to the coverage they are eligible for. Many business offices rely on software programs to manage their billing, and those programs haven't caught up to the Jimmo v. Sebelius court decree issued on January 24, 2013.

Need for skilled care is the requirement for this coverage of nursing home room and board. "Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities," the manual states.

For example, Medicare will consider a nursing home resident's maintenance therapy program to be a skilled service, if the therapy can be safely and effectively performed only by, or under the supervision of, a qualified therapist.

The Code of Federal Regulations offers this example: "A patient with Parkinson's disease may require the services of a physical therapist to determine the type of exercises that are required to maintain his present level of function." The list and its qualifications is simplified by

  • the initial evaluation of the patient's needs,
  • the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, and
  • the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record."

(Learn more about the Difference Between Skilled Nursing and a Nursing Home.)

Medicare Payments for Home Care

The requirement for skilled services also applies to home care paid by Medicare. The Code of Federal Regulations elaborates on this requirement:

"A patient was hospitalized following a heart attack. Following treatment he returned home. Because it is not known whether increasing exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated in the patient's home. The patient's necessity for skilled observation must be documented at each home health visit until the patient's clinical condition and/or treatment regimen has stabilized.

"If the patient's overall condition supports a finding that recovery and safety can be ensured only if the total care is planned, managed, and evaluated by technical or professional personnel, it is appropriate to infer that skilled services are being provided."

Many other services that qualify as skilled nursing services, and skilled rehabilitation, are listed in the Code of Federal Regulations, 42 CFR 409.33 (a) (b) and (c).

Understanding these rules can help you be a better health care advocate, as well as a good money manager who knows when Medicare should continue paying for nursing home room and board.

As always, perform your own thorough due diligence by researching, reading and asking questions so that you and your family can make the best informed decisions for the situations of your loved one. Their manual offers what is perhaps the most solid piece of instruction in its conclusion saying “these cases must be carefully documented.” The bottom line is that vigilance and advocacy by family members will be necessary to protect a loved one’s eligibility for Medicare nursing home coverage.

John L. Roberts, J.D., is an Elder Law Attorney serving clients in Hampden County, MA. After practicing for 15 years, he confronted the challenges of family caregiving when his own father developed dementia. The experience transformed his practice, enabling him to help clients who are family caregivers from a place of true understanding.

Visit Law Office of John L. Roberts

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39 Comments

Yes, I do understand that Medicare was not intended for long term custodial care. My mother went to a nursing home/rehab center that was supposed to wean her off her ventilator. Right at the time the Medicare 100 days ended, she developed a serious UTI infection. This should have been caught as she was on a catheter, so any change in her urine color should have been reported to the nurse. Up until the UTI, she had physical therapy and was able to stand easily, and was doing well weaning off the vent. After the UTI, no more physical therapy until she went on a trach collar, and now she wasn't doing well with the weaning. Finally after her money ran out, I made the choice to take her home. The nursing home was planning on kicking her out anyway. She came home on the vent and unable to walk. Seven months after being home, she no longer needed the ventilator. A month later, the trach tube was removed. There was no weaning process at home, as there wasn't anyone to help me with this. She is off most of the medicine that was prescribed by the nursing home. Her feeding tube is out, and she is eating solid food at home. The only lingering problem is she is not able to walk. It took months before I was able to obtain access to a physical therapist to visit her at home. It took months for long term home care under Medicaid to kick in. She needs long term physical therapy, not just 20 visits under Medicare. I understand that people have taken advantage of the system under Medicare and Medicaid, but it is not fair to penalize those people that really need the services. I am paying out of pocket for incontinence products at what I have received from Medicaid gave my mother an infection. My family is not looking for loopholes nor do we want to use the services for the long term. We just want my mother to be able to walk on her own so we don't need the extra services. Just to let you know, it took me 2 months to obtain a wheelchair so I can get my mother to a doctor. My family has never asked for help before, but due to my mother's financial situation she had to apply for long term home care. The whole Medicare/Medicaid system does not work for the honest person, and needs to be overhauled.
What people don't understand is that Medicare was never intended to pay for long-term, custodial care in a nursing home where it is basically "room and board." I am not referring to a skilled nursing facility for rehab after a cardiovascular event or hip replacement - which is a different situation. But even in the latter situation, they are still limited to a maximum of 100 days - just over 3 months.

Don't forget that you and I, as taxpayers, are footing the bill for patients and their families who abuse the system - under both Medicare and Medicaid. We should never encourage people to look for "loopholes" to suck money out of these government programs since it comes out of our own pockets, indirectly.
This is a very curious article. The opening statement "don't let the NH business office tell you...." disregards the Real Question: will Medicare pay the bill? Until we have thousands of verified cases where Medicare HAS PAID for long-term care, the jury is still out. I don't believe that reading about this "hopeful idea" on this chat board, is a good substitute for actual case histories. If I were in the position of needing LTC for mom, the Last Place I would ask is Medicare. This article is just wishful thinking. I suspect the references mentioned are taken out of context.