Not everyone is aware that Medicare benefits are available for skilled nursing home care. Medicare does pay for covered services in certified skilled nursing homes. There are, however, certain conditions which need to be met in order for benefits to be paid out.
First and foremost, according to the website Medicare.gov, the care that an individual is receiving must be more than custodial (i.e., help with bathing and/or dressing). The care must be considered skilled nursing care that is medically necessary.
There are several criteria that need to be met. These include:
- The patient must have days left in his or her benefit period (the number of days Medicare will pay for skilled nursing care).
- The patient must have had a qualifying (3-day) hospital stay.
- A doctor must decide that skilled care is needed.
- The nursing facility must be Medicare certified.
- The patient must need care for a hospital related medical condition, or a condition that began while the patient was in a skilled nursing facility for a hospital related medical condition.
Medicare pays for skilled nursing home care according to the following schedule:
- For days 1-20, Medicare pays 100% of covered services.
- For days 21-100, Medicare pays all but the $152 copay for covered services.
- For days 101 and beyond, Medicare pays nothing.
Finally, in order to qualify for Medicare payment of skilled nursing facility services, a patient must:
- Have had a break in skilled nursing care for 30 days and undergo a new 3-day hospital stay, or
- Have had a 60-day break in skilled care, which renews the skilled nursing facility benefit.
With that said, the patient’s copay will also differ based upon what type of Medicare supplement insurance he or she has. Policy provisions, or even if the patient qualifies for TriCare or Veterans Assistance benefits, will also affect the amount that is paid out of pocket.
In negotiating the labyrinth of the Medicare payment schedule, a healthcare consultant or geriatric care manager can be of inestimable value in helping to determine what, exactly, will be covered, and how much it will cost. Contact MIR Senior Care to determine what the best and most affordable solution for your loved one is.