Medicare Coverage and Nursing Homes

Nursing homes specialize in taking care of older people once they can no longer take care of themselves. A nursing home ensures that older people eat properly and helps seniors with custodial duties such as general hygiene and taking their medications. Most of the care provided by a standard nursing home does not include skilled nursing care. In fact once a person is in need of medically necessary skilled nursing care they will generally have to change nursing homes and this can be very disruptive.

Some institutions have what is known as stepped care. This means that they offer various levels of care at one facility. In a stepped care nursing home it is possible to enter the nursing home for basic custodial care and remain at the facility as one's health deteriorates. Similarly, a patient may be able to enter the nursing home for skilled nursing care and then transfer into lesser levels.

Overall, entering a nursing home that provides a large range of care options is often the best choice. Not only will you avoid having to choose a new facility when your health deteriorates; the administrative officers and medical personal are more highly trained and this can be a real asset.

What will Medicare Cover for Nursing Homes?

Basic custodial nursing home care is NOT covered under Medicare Part A or Part B. Additional forms of Medicare coverage exist that affect patient's costs for nursing homes. These include:

  • Prescription drug coverage is available under Original Medicare Part D.
  • Medigap insurance (supplemental insurance) can help pay for some of the co-insurance and co-payments of covered care.
  • Private insurance companies run Medicare Advantage Plans and they can be used instead of Original Medicare. All Advantage Plans are different and what they will and won't pay for varies. However, some of them have more lenient rules related to custodial care than Original Medicare.

Medicare does cover skilled nursing care and some home custodial care. Skilled nursing care is different from custodial care in that it is designed to be short-term and to rehabilitate a patient back to wellness. Before Medicare will pay for a skilled nursing facility the patient must meet very strict rules. These include:

  • The patient must have Medicare Part A.
  • The patient must have been hospitalized for at least three nights for the condition.
  • A Medicare approved physician must order care.
  • Care must be received in a Medicare approved facility.
  • Most importantly the patient must require daily skilled care administered by either a nurse or a therapist.

When these conditions are met, Medicare will pay for most of the costs associated with the Skilled Nursing Facility for the first 20 days. After this time, the patient will pay large daily co-pay up to 100 days. After 100 days the patient pays for 100% of the costs for care unless they are eligible for hospice care. If the Medicare recipient also has a Medigap policy patient costs are covered up to 100 days and the length of coverage is extended.

In summary, Medicare does not cover custodial nursing home care but it does cover short-term skilled nursing care under most circumstances. Having a care facility and a doctor that is approved by Medicare is instrumental in navigating this process properly and reducing patient out of pocket expenses.