Nursing Facilities (Nursing Homes): Medicare Coverage

What is a nursing facility?

A nursing facility is a long-term care facility. Nursing facilities provide care for people with illnesses and disabilities that make it impossible for them to stay in their own homes. Nursing facilities are not hospitals, but they do provide a room; meals; help with daily activities such as eating, bathing, and dressing; and supervision. Nursing facilities are also called nursing homes or care centers, and because the facility is a home, people who live there are called residents.

Aides provide most of the personal care. Physical, occupational, and speech therapists may also be available. If the nursing facility provides wound care or uses tube feedings or IVs it is called a skilled nursing facility. A skilled nursing facility may be located within the nursing facility or care center.

When does Medicare pay for nursing facility care?

Generally, Medicare pays for care in a skilled nursing facility when these 5 conditions are met:

• A doctor certifies that you need skilled nursing care. This is different from custodial care. Skilled nursing care is provided by trained medical professionals. This includes nurses, doctors, and physical therapists. Examples of skilled nursing care are injections, tube feeding, and dressings on wounds. Custodial care can be done by people who have no medical training. Examples of custodial care are help with walking, bathing, dressing, or feeding.
• You need daily care that can be provided only in a skilled nursing facility. The care must be either given by or provided under the supervision of licensed nurses.
• You were in a hospital 3 days in a row, not counting the day of going home, before entering the skilled nursing facility.
• You were admitted to the facility within 30 days after leaving the hospital.
• The condition for which you are receiving skilled nursing care was treated in the hospital or started while you were getting care in the hospital.

How long will Medicare pay?

After you have been in a hospital for at least 3 days, Medicare will pay for care in a skilled nursing facility for up to 100 days in a benefit period. A benefit period begins when you go into the hospital. It ends when you have not received any hospital care or skilled nursing care for 60 straight days.

If you go into the hospital for at least 3 days after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

If you leave the skilled nursing facility and reenter it within 30 days, Medicare will continue to pay for services until you have reached the 100 days of coverage.

• Part A Medicare pays 100% of skilled nursing care for the first 20 days.
• For the next 80 days you pay 20% for each day and Medicare pays 80% of the cost.
• Medicare does not pay for skilled nursing facility care after 100 days, or before the 100th day if you no longer need skilled nursing or rehabilitation services. You may still need custodial care. Custodial care is help with eating, bathing, taking medicine, and going to the bathroom. Medicare does not pay for custodial care if that is the only care you need. You pay for custodial care until your medical costs exceed your income and you qualify for Medicaid. Medicaid may then pay for custodial care.

A skilled nursing facility cannot demand a cash deposit as a condition of admission unless it is certain that Medicare will not cover you.

Where can I go if I have a concern or complaint about a nursing facility?

Contact the facility's administrator or director of nursing when you have concerns. If your problem is not taken care of, call the local ombudsman. The ombudsman, also called an ombuds, is an advocate for people who live in care facilities who may not be able to speak out for themselves. Their job is to see that residents' rights are not abused. All states have ombuds programs to handle complaints in nursing facilities. The ombuds visits each facility and tries to get to know the residents so they will call if they have problems. The phone number for the ombuds is posted in each facility.

For further information contact:

American Association of Homes and Services for the Aging (AAHSA) Phone number: 1-202-783-2242 Web site: http://www.aahsa.org.

Written by Carolyn Norrgard, RNC, BA, MEd, and Carol Matheis-Kraft, PhD, RNC, for RelayHealth.
Published by RelayHealth.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.