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Medicare’s nursing home coverage may be less than you think

While Medicare covers nursing home stays, exactly what it covers is complicated and in some cases it can be much more limited than people think. If you or a loved one might need a stay in a nursing home, it’s very smart to understand the rules ahead of time, so you can be prepared and not have an unpleasant surprise.

Medicare covers up to 100 days of “skilled nursing care” per illness. However, in order for the care to be covered, the patient must enter a nursing home (or a Medicare-approved “skilled nursing facility”) within 30 days of a hospital stay, and the hospital stay must have lasted at least three days. The care in the nursing home must be for the same condition as the hospital stay. In addition, the patient must need “skilled care.” This means that a doctor must order the treatment, and the treatment must be provided daily by a registered nurse, physical therapist, or licensed practical nurse.

Finally, Medicare covers only “acute” care – as opposed to “custodial” care. This means it covers care only for people who are likely to recover from their conditions, and not for people who need ongoing help with performing everyday activities, such as bathing or dressing.

However, even this is complicated. If a patient needs skilled nursing care to maintain his or her health status (or to slow deterioration), then the care is generally covered by Medicare. In addition, patients often receive an array of treatments that individually 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 generally provides coverage.

If Medicare covers a nursing home stay, it will pay 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. After 20 days are up, there is a significant co-payment ($133.50 a day in 2010). This co-payment may be covered by a Medigap policy. After 100 days are up, the patient is responsible for all further 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 non-coverage. The nursing home cannot discharge you until the day after the notice is given. The notice should explain how to file an appeal. There are several levels of appeals, and in many cases it’s best to have an attorney guide you through the process.

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