Nursing Homes

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By Sharon Johnson, February 10th, 2009

Medicare Services in a Nursing Home

Medicare Part A pays for up to 100 days of care in a Skilled Nursing Facility (SNF) as long as the patient needs care that can't be provided in the home. This includes therapies such as Physical Therapy, Occupational Therapy, Speech Therapy, Wound Treatments, IV Therapies, or other specialized treatments that must be performed by or at the direction of a Registered Nurse.

In order to qualify for Medicare to pay for SNF services the patient must have stayed in the hospital for three consecutive days (over three midnights) within the past 30 days. It's important to understand that all hospital admissions don't necessarily meet this criteria because sometimes a patient is placed on an Observation Status or is discharged before the three days are up. If the patient doesn't present a medical need for acute care, he'll be discharged whether or not he needs follow up care in a facility. This can be frustrating for patients and their families, who then must pay out-of-pocket for the follow up care he needs or make other caregiving arrangements.

There is no guarantee that the patient will qualify to stay the full hundred days -- the SNF has to justify to Medicare on an ongoing basis why the patient continues to need treatments that can't be provided at home, or in an outpatient setting. Patients are sometimes discharged from Medicare services before they believe that they are ready, but if they have met their goals and aren't able to progress any further Medicare won't pay for the patient to remain in a facility.

Under the Original Medicare Part A Benefit, there are the following costs to the patient for Skilled Nursing in a facility:

The first 20 days in a benefit period are free to the patient.

Days 20-100 require a co-payment from the patient in the amount of
$133.50 per day (2009 amounts).  This amount is often covered at
least in part by a Medicare Supplemental Policy or might possibly be
covered by Medicaid, although the current state of the economy there
are many cutbacks associated with Medicaid.    

Sometimes a patient isn't able to participate in therapies or isn't ready to go home - this type of care is considered to be Custodial Care. Medicare doesn't pay for Custodial Care, and if the patient remains in the Skilled Nursing Facility he must pay privately or have another payment source available for his room & board.

If a patient is already a resident in a nursing home, Medicare Part B might possibly pay for him to receive rehabilitation services to keep the patient maintaining at his highest level of functioning. Medicare will only pay for the therapy, and the patient's regular payment source will continue to pay for the Custodial Care. It depends upon the patient's ability to benefit from therapy as to whether he qualifies for therapy under the Medicare B benefit.

Medicare Part A services bring in the most revenue, so many nursing homes offer Medicare services in addition to the Custodial Care they provide to patients. If there is only one bed available, the nursing home will accept a Medicare patient before they accept a patient with another payment source. Other payment sources include Private Pay, Medicaid, VA Benefits, Long-Term Insurance Policies. I will cover these payment sources in future articles.

Sharon Johnson, BSW, is a Social Worker with over 18 years of direct experience working with the elderly. She is the author of several books on senior care issues and Executive Director of Case Management Solutions, LLC. For more information on nursing home placement, read her book "Taking the Mystery out of Nursing Home Placement" at www.cmseldercare.com