Posted by Medicare is a federal health insurance program that provides coverage for millions of seniors and people with disabilities across the United States. For those who require care in a nursing home, understanding the ins and outs of Medicare coverage can be a daunting task. This article will explore the various aspects of Medicare coverage for seniors in nursing homes, including eligibility, covered services, and potential costs.
Eligibility
- First, the patient must be aged 65 or older, or have a disability that meets the Social Security Administration’s definition of disability. This means that they must have a physical or mental impairment that is expected to last at least a year or to result in death, and that prevents them from doing substantial gainful activity.
- Second, the person must be enrolled in Medicare Part A and must have a qualifying hospital stay. A qualifying hospital stay is defined as an inpatient hospital stay of at least three consecutive days, not including the day of discharge. It is important to note that time spent in observation does not count towards the three-day requirement.
- Third, they must need skilled nursing care on a daily basis or skilled rehabilitation services on a daily basis. Skilled nursing care refers to services that can only be performed by a licensed nurse or therapist and require the skill of a professional. Examples of skilled nursing care include wound care, tube feeding, and physical therapy. Skilled rehabilitation services refer to therapies such as physical therapy, occupational therapy, and speech therapy that are necessary for the person’s recovery and must be provided by a licensed therapist.
It is also important to note that Medicare coverage for nursing home care is intended to be temporary and is only provided for a limited amount of time. Medicare will cover up to 100 days of skilled nursing care per benefit period, with the first 20 days covered in full and the remaining days subject to a daily coinsurance payment. After 100 days, the person is responsible for all costs of care unless they have private insurance or qualify for Medicaid.
Additionally, Medicare coverage for nursing home care is only provided if the nursing home is a Medicare-certified facility. To be certified, the nursing home must meet certain standards for quality of care and must be inspected regularly by state and federal agencies. It is important to confirm that a nursing home is Medicare-certified before enrolling.
Covered Services
Once a person is deemed eligible for Medicare coverage for care in a nursing home, they may be eligible for several covered services. These include:
- Room and board: Medicare will cover the cost of a semi-private room, meals, and other basic amenities.
- Skilled nursing care: Medicare will cover the cost of skilled nursing care, which may include services such as wound care, physical therapy, and medication management.
- Rehabilitation services: Medicare will cover the cost of rehabilitation services, including occupational therapy, speech therapy, and physical therapy.
- Medical equipment: Medicare will cover the cost of necessary medical equipment, such as wheelchairs or oxygen tanks.
- Hospice care: If a person is terminally ill, Medicare will cover the cost of hospice care in a nursing home.
Medicare also covers certain medical services provided by the nursing home, such as medication management, physical therapy, occupational therapy, and speech-language pathology services. In 2018, nearly 10.3 million Medicare beneficiaries received at least one skilled nursing facility service, and Medicare paid $29.5 billion for these services (CMS, 2020).
Medicare covers hospice care for beneficiaries who have a life expectancy of six months or less, as certified by a physician. Hospice care can be provided in a nursing home, and it includes services such as nursing care, social work services, medical equipment and supplies, and counseling services. In 2019, nearly 1.6 million beneficiaries received hospice care services, and Medicare paid $20.5 billion for hospice care (CMS, 2020).
Overall, Medicare provides significant coverage for seniors in nursing homes, but it is important to understand the specific criteria and limitations for coverage.
Potential Costs
While Medicare coverage for care in a nursing home can be a lifeline for many seniors, it is important to note that there may be costs associated with this coverage. According to Genworth’s 2020 Cost of Care Survey, the average cost of a semi-private room in a nursing home in the United States is $7,756 per month, while a private room costs $8,821 per month. These costs can vary depending on location, with some areas costing significantly more. For example, in Alaska, the average monthly cost of a semi-private room in a nursing home is $30,219, while in Oklahoma, the average monthly cost is $5,323.
Medicare coverage for nursing home care is only available for a limited time, and after that time, seniors may be responsible for the costs associated with their care. In 2021, the Medicare Part A deductible for inpatient hospital stays was $1,484, and the coinsurance costs for a stay in a skilled nursing facility were $185.50 per day for days 21 through 100. Beyond day 100, seniors are responsible for all costs associated with their care.
It’s important to note that Medicare does not cover all services provided in a nursing home. For example, Medicare does not cover long-term custodial care, which includes assistance with activities of daily living, such as bathing, dressing, and eating. Additionally, Medicare does not cover the costs of personal care items, such as toothpaste or shampoo.
Understanding the potential costs of Medicare coverage for nursing home care is essential for seniors and their families to make informed decisions about their healthcare needs. It’s important to explore all available options, including Medicare Advantage plans and other forms of insurance, to ensure that seniors receive the care they need without facing significant financial burdens.
Conclusion:
Navigating Medicare coverage for senior care in nursing homes can be a complex and confusing process. However, by understanding the eligibility requirements, covered services, and potential costs, seniors and their loved ones can make informed decisions about their care. It is important to consult with healthcare providers and financial advisors to ensure that all options are explored and that the best possible care is received. Medicare coverage for care in a nursing home can provide peace of mind and support for those in need, and it is important to take advantage of this valuable resource when it is needed most.
References:
Centers for Medicare & Medicaid Services. (2021). Medicare coverage of skilled nursing facility care. https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
Kaiser Family Foundation. (2021). Medicare’s role for older beneficiaries. https://www.kff.org/medicare/fact-sheet/medicares-role-for-older-beneficiaries/
U.S. Department of Health and Human Services. (2021). Medicare. https://www.hhs.gov/medicare/index.html
U.S. Government Publishing Office. (2021). Medicare and you 2022. https://www.medicare.gov/pubs/pdf/10050-medicare-and-you.pdf