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Medicare covers Skilled Nursing services ONLY. Medicare will not, under any circumstances, pay for Intermediate or Custodial nursing facility care.
Medicare Skilled Nursing Facility benefits fall under Medicare Part A.
Skilled Nursing and Rehabilitative services are defined as:
1. Medically necessary.
2. Ordered by a physician.
3. Performed by skilled personnel (i.e,, physical therapist, respiratory therapist, occupational therapist, etc.).
Medicare covers Skilled Nursing Facility care if the following conditions are met:
1. Patient must have spent three overnights as an admitted hospital patient (be wary of “observation” stays in hospital…they do not count toward the three day requirement).
2. Be admitted to a Medicare participating facility.
3. Be admitted within 30 days of hospital discharge.
4. Be admitted for the same condition for which they were hospitalized.
If the above conditions are met then for each Benefit Period:
1. Medicare will pay all charges for the first 20 days.
2. Medicare will pay all charges except for a $161 per day co-pay for the next 80 days (2016). This co-pay may be covered by Medicare supplement or other private insurance.
3. Medicare Skilled Nursing Facility benefits end after 100 days of care per Benefit Period.
What is a “Benefit Period”?
A Benefit Period begins the day (overnight) the beneficiary is admitted to a hospital as a Medicare patient and ends when they been out of the hospital or have not received Medicare Skilled Nursing Facility care for at least 60 days in a row.
In other words, Benefit Periods are separated by 60 days during which the Medicare beneficiary has not received care in a hospital or Skilled Nursing Facility.
After 60 days Medicare Part A benefits “renew” in that the beneficiary will receive all benefits as if benefits had not been previously received (with the exception of “lifetime reserve days” which do not “renew” and do not apply at all to Skilled Nursing Facility benefits). New deductibles and co-pays will also apply. So, too, will the beneficiary have to again meet the hospital stay requirement.
Remember that just because there is a potential 100 day Skilled Nursing Facility benefit per benefit period it does not mean the beneficiary “automatically” will receive the full 100 days.
To continue to receive Medicare Skilled Nursing Facility benefits during the covered 100 days the patient:
1. Must be able to participate in prescribed therapies.
2. Must be willing to participate in prescribed therapies.
3. Must be “progressing” in treatment.
If the patient stabilizes or “plateaus” in treatment, they may no longer qualify for skilled services and Medicare benefits will terminate…even if the patient is not capable of caring for themselves or they have not received 100 days of coverage.
This is where Medicaid comes in as the payee of last resort for nursing home care other than skilled or when Medicare skilled benefits are exhausted.
Caveat: The above is applicable to “Original” Medicare. If a beneficiary is covered under a Medicare Advantage Plan (Medicare Part C) actual benefits may vary in terms of co-pays and coverages. Contracts and benefits vary. Consult the contract for details.
There can also be other variables, depending on which company carries your health insurance. Read your policy carefully. For our mom the $100 a day co-pay started on day one.
be considered an “outpatient?” Your hospital status (whether the hospital
considers you an “inpatient” or “outpatient”) affects how much you pay for
hospital services (like X-rays, drugs, and lab tests) and may also affect whether
Medicare will cover care you get in a skilled nursing facility (SNF) following
your hospital stay {EQ}
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