Does Medicare Pay for Nursing Home Care

I’ve already got Medicare – does Medicare pay for Nursing Home Care costs? We’ve heard that question hundreds of times over the years. You probably already have a Medicare card which you use when you go to doctor’s appointments, for prescription drugs, for hospital visits, for care given by some home health agencies, hospices and some related medical needs. It makes perfect sense to think that Medicare would pay for Nursing Home care. After all, you are sick and have go to a Nursing Home to receive care. Medicare should continue to pay for that level of care as well, right? The short answer is, Medicare only pays for Nursing Home care for a short specific time period in specific situations. Sorry for the vague answer, but we’ll try to get to the bottom line basics in this brief blog post.

WHEN Does Medicare Pay for Nursing Home?

Now we know that Medicare does occasionally pay for some Nursing Home care. The question becomes, “OK, when does Medicare pay?” As referenced above, Medicare may pay (if you qualify) for a short period of time (up to 100 days) for rehabilitative care received in a Nursing Home. That was a loaded sentence, so let’s break it down.

Medicare may pay if you are qualified. What do I mean by “qualified”?

  • First you must be qualified to receive Medicare benefits, meaning you must be age 65, blind or disabled. If you are reading this, over age 65 and are currently on Medicare, you have jumped this hurdle already.
  • The second qualifying hurdle is that you must have had a 3 day qualifying stay in a hospital. Here’s another loaded sentence: To qualify for Medicaid, the hospital must admit you as a patient during your stay. We will discuss why further below.

For a short period of time – up to 100 days.

Medicare will not pay for your long term care stay in a Nursing Home for the long-haul. It will pay only during the time necessary for you to rehabilitate to the point where you can go home. In many situations, Medicare will not pay at all or will pay for only a few days. For example, say a person with Alzheimer’s was admitted to the hospital for flu symptoms and later discharged after a several day hospital stay. It is likely in this scenario that Medicare would not pay any Medicare benefits for rehabilitative care. Alzheimer’s is the only ongoing ailment that can’t be improved with rehabilitative care.

For Rehabilitative Care

Medicare will pay only for rehabilitative care. The idea is that you had a health challenge (ex. You fell and broke a hip) and Medicare’s role is to pay to rehabilitate you. The goal is to get you up and functioning again and send you back home. Most Nursing Homes have several therapists, either on staff or who contract with the Nursing Home to provide care to residents at specific times during the week.

Received in a Nursing Home or Rehab Hospital

Most Nursing Homes have separate rehab wings reserved for short-term residents who are receiving rehabilitative care. Additionally, there are free-standing rehabilitation facilities that provide rehabilitative care and receive Medicare as payment. These facilities are separate from nursing homes.

Download Your FREE Medicare Tip Sheet

How Much Does Medicare Pay?

If you do qualify to receive Medicare coverage for a rehab stay, then Medicare will pay 100% of your rehab stay for days 1 – 20. Starting day 21, Medicare only pays 80% and you pay 20%. While this sound really good, just know that your 20% can be very expensive. This is where it pays to have a good Medicare Supplement policy. Your Medicare Supplement policy will pay this 20% co-pay during the time that Medicare pays. However, when Medicare stops paying, your Medicare Supplemental policy also stops paying.

Ex. Momma breaks a hip and goes to the hospital for surgery. From there, Momma is discharged to a Nursing Home for rehabilitative care. In this example, Medicare paid 100% of Momma’s care for days 1 – 20. Starting at day 21, Medicare paid only 80%. The cost of Momma’s 20% was $167.50 per day for days 21 – 100. Unless Momma had a good Medicare Supplement (Medigap) policy, she would pay this per day amount out of pocket. Your situation may be substantially different from this example. If you have issues with Medicare payment issues, contact the hospital and/or Nursing Home for an explanation. If necessary, contact an Elder Law Attorney for assistance.

Observation Status vs. Admitted as a Patient

During your hospital visit, you need to have been “admitted”. It will not count if you are there on “observation status”. Yes, this seems like a technicality. However, this “technicality” often prevents many people from receiving paid rehabilitative care in a Nursing Home. If your Loved One is in a hospital and you are one of the adult children or Family Caregiver who is serving as their advocate*, then it is critical that you ask and receive an answer to this “admitted or observation status” question. Hospitals are strictly regulated in this area and can’t just choose “observation status” on a whim or “because they do/don’t like me.” However, patient status is sometimes a grey area  that can be discussed with the hospital staff. If you know that Momma will need rehabilitative care after being discharged from the hospital, this is certainly a good discussion to have with her doctor and professional medical staff.

*For a good article and explanation of serving as advocate, I refer you to a blog article entitled Momma’s in the Nursing Home – Now What?. This is on our separate Help Me Help Momma website. HelpMeHelpMomma.com serves up information for Family Caregivers taking care of a declining Loved One at home.

Medicare vs. Medicaid

Medicare

Medicare and Medicaid are two very different programs. Because they have similar sounding names, it is easy to confuse them. In this blog post, we have been discussing Medicare. Medicare will pay for only (up to 100 days) rehabilitative care. Your Loved One may receive 100 days of Medicare in full. They may also have a great Medigap policy that pays the 20% co-pay amount discussed above. After 100 days, however, Medicare payments will be DONE.

If your Loved One’s care must continue in a Nursing Home, they will be considered a private pay resident after day 100. This means that they pay for their Nursing Home care out of pocket until they run out of money. However, they may seek other options for governmental assistance. The average cost of Nursing Home care in Arkansas in 2018 is $5,383 per month. It doesn’t take long to burn through many bank accounts.

Medicaid

That’s where Medicaid comes in. Medicaid is the long-haul payor for Nursing Home long term care. The most unfortunate thing about Medicaid is that many people spend ALL of their money for their Nursing Home care before attempting to qualify for Medicaid. The truth is that most could qualify for Medicaid assistance much sooner. By applying and qualifying earlier, they often can preserve substantial assets for the benefit of their spouse or children. For more information on Medicaid and how to protect and preserve some of your Loved One’s hard-earned assets, read our blog post entitled How to Get Medicaid to Pay for Momma’s Nursing Home Care.

Download Your Free Medicare Tip Sheet

Download your Free Medicare Tip Sheet (including one big thing that many Nursing Homes get wrong) – just click this Medicare Tip Sheet link here . Medicare only pays for a short but critical period of time during which your Loved One is attempting to rehabilitate. It’s important to recognize the big things that can block your Loved One’s attempt to get Medicare coverage for the medical care that they desperately need.

Best wishes as you attempt to help your Loved One get the care they need and access the available resources to help pay for this care.

Disclaimer- We always attempt to give useful information. Nothing contained herein was intended as legal advice or information that you should act on to obtain a specific result in your particular case. Situations vary greatly and laws change frequently and are subject to various interpretations. It is critical that you contact your Elder Law Attorney or other trusted professional to discuss the particulars of your case before taking any actions in your particular situation.