Which Should I Choose? Nursing Home Care vs. Hospice Care
End-of-life care decisions are never easy, but many Medicare recipients are being forced to choose between nursing home or ho...Read more
Many people believe that Medicare covers nursing home stays. In fact, Medicare's coverage of nursing home care is quite limited.
Medicare covers up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered.
The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.
In order for a nursing home stay to be covered by Medicare, you have to meet the following requirements:
Note that if you need skilled nursing care to maintain your status (or to slow deterioration), then the care should be provided and is covered by Medicare.
In addition, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient's care and status. In such cases, Medicare should continue to provide coverage.
When you leave a hospital and move to a nursing home that provides Medicare coverage, the nursing home must give you written notice of whether the nursing home believes that you require a skilled level of care and thus merit Medicare coverage.
Once you are in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies.
Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($194.50 a day in 2022). This copayment may be covered by a Medigap (supplemental) policy. After 100 days are up, you are responsible for all costs.
If you are in a nursing home and the nursing home believes that Medicare will no longer cover you, it must give you a written notice of noncoverage. The nursing home cannot discharge you until the day after the notice is given.
The notice should explain how to file an expedited appeal to a Quality Improvement Organization (QIO). A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries. You should appeal right away. You will not be charged while waiting for the decision, but if the QIO denies coverage, you will be responsible for the cost. If the QIO denies coverage, you can appeal the decision to an Administrative Law Judge (ALJ). It is recommended that a patient hire a lawyer to pursue an appeal. Check out an article from the Center for Medicare Advocacy on nursing home discharges.
You cannot rely on Medicare to pay for your long-term care. Contact an attorney near you to create a long-term care plan.
Get more information on Medicare.