What Does Medicare pay for Nursing Home?

What Does Medicare pay for Nursing Home?

If your mother goes to a skilled nursing home, Medicare Part A provides 90 consecutive days of coverage. Also, it provides an additional 60 total days of coverage (“lifetime reserve days”) over the course of her life. To earn these benefits, the following requirements must be met:

  1. It must be a “skilled care” facility. There are different types of care such as “custodial” or “intermediary.”
  2. The Skilled Nursing Facility (SNF) must be preceded by a hospital inpatient stay of at least three consecutive days, not counting the day your mother was discharged;
    1. Example: If your mother came to the emergency room and spent one day there and then two days in the hospital as an inpatient, she would not meet the requirement because her first day in the emergency room was not considered inpatient care.
    2. Example: If she came to the same hospital, but she was admitted to the hospital for three days and discharged on the fourth, she would then meet the 3-day inpatient requirement.
  3. Admission to the SNF must occur within 30 days of discharge from the hospital unless it would be medically inappropriate.

Medicare does not pay everything for the full 90 days. Rather, it will pay the following:

  1. Days 1-60: Full cost
  2. Days 61-90: Your mother will have to pay a coinsurance of $352 per day. The coinsurance usually exceeds the private pay cost in Texas. However, your mother’s Medicare Supplement Insurance should cover the copayment. If she is eligible for the QMB Program (see Chapter 23), then that will cover the cost.
  3. Days 91 and beyond: Your mother will have to pay a coinsurance of $704 per lifetime reserve day used.
  4. After lifetime reserve days are spent: All costs are on your mother.

Your mother can actually reset the time by remaining out of either hospital care or “skilled” nursing care for 60 continuous days. After this period, the time starts again and she can get the same benefit as long as the above requirements are met.

Medicare Prescription Drug Coverage (“Part D”)

If your mother qualifies for Medicaid long-term care or a Community-Based Alternative program, she can receive full reimbursement for her prescription medication(s). Your mother may qualify for this benefit even if she is subject to the penalty period for a transfer.

In order for this to happen, however, your mother will need to have a Medicare Drug Plan. Please do one of the following:

  1. Visit the website[1],
  2. Complete a paper enrollment form[2],
  3. Call the plan provider, or
  4. Call Medicare at 1-800-633-4227 (1-800-MEDICARE).

The Medicare Hospice Election

Since 1983, Medicare has covered the cost of hospice. This is one of the most generous benefits provided by Medicare, as with it, your mother may receive full medical support. Whether being cared for in her own home or temporarily at an inpatient facility or hospital, she can choose hospice as long as the following conditions are met:

  1. She has Medicare Part A hospital insurance;
  2. Her primary physician and the hospice physician sign a statement identifying at least one terminal condition (meaning she is expected to die within six months if her condition runs its normal course);
  3. Your mother or her representative signs a statement waiving the right to treatment of the terminal condition; and
  4. She enrolls in a hospice program that is approved by Medicare.

Medicare hospice benefits will cover a number of critical resources, including: doctor and nurse care, medical equipment and supplies, medication to control pain, home health aides, dietary counseling, and grief and loss counseling for family members. In addition, it will pay for a short-term hospital and nursing home care. If your mother intends to stay in a nursing home while receiving hospice care, Medicare will not cover her nursing home expenses.