Medicare & Nursing Homes
Most health insurance plans, including Medicare, do not cover long-term stays in nursing homes. Medicare will pay for stays in skilled nursing facilities or rehabilitation centers if the patient meets certain conditions. Because of this people often think that Medicare will also pay for nursing home costs, but this is not the case.
A stay in a skilled nursing facility (SNF) requires that the patient has a condition such as an injury that calls for daily skilled care, such as speech therapy or daily medication supervision. Medicare will cover the first 100 days of a stay in an SNF. However, if the patient just needs assistance with everyday tasks like eating or bathing, their nursing home bills will not be covered by Medicare.
The average annual cost of a nursing home stay is over $90,500, according to a 2012 study by MetLife. This expense is prohibitive for most families, but there are ways to offset the costs if a nursing home becomes necessary.
Before you or your loved one needs to enter a nursing home, consider home health services (HHS) instead. Your doctor will determine if you are a good candidate for HHS, and if you are homebound he or she must certify that you are homebound. To be homebound means you either have trouble leaving your home without the assistance of a cane, crutches, wheelchair, another person, walker, or special transportation, it is not recommended for you to leave your home by your doctor, or it is normally very difficult to leave your home due to the amount of effort required. If you attend adult day care you can still receive HHS.
If you meet eligibility requirements, then Original Medicare (Parts A and/or B) will cover HHS provided by a Medicare-certified home health agency at no cost to you. HHS include the following:
- Part-time or Intermittent skilled nursing care (other than just drawing blood)
- Medical social services such as counseling or help finding resources in your community for emotional and/or social concerns
- Part-time or intermittent home health aide services
- Medical supplies for use at home
- Durable medical equipment (under Original Medicare you must pay for 20% of the Medicare-approved amount for DME)
- Injectable osteoporosis drugs
- Physical therapy
- Speech-language pathology services
- Continued occupational therapy services
Part-time or intermittent skilled nursing care is defined as care you need to receive less than 7 days each week or less than 8 hours per day over a period of 21 days or less with some exceptions due to special circumstances. The latter three services (physical therapy, speech-language pathology, and continued occupational therapy) are only covered when the services are safe, specific, and deemed an effective treatment for your condition by your doctor. Moreover the amount, frequency, and time period of the services must be reasonable, and the services must be complex or only qualified therapists can perform them safely and effectively. In order to be eligible for coverage for physical therapy, speech-language pathology, or continued occupational therapy, you must meet one of the following requirements:
- Your condition must be expected to improve in a reasonable and generally predictable period of time
- You need a skilled therapist in order to safely and effectively make a maintenance program for your condition OR you need a skilled therapist in order to safely and effectively perform maintenance therapy for your condition
Medicare does not cover the following HHS:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services: shopping, cleaning, laundry, etc. when this is the only care you need and when these services are not related to your plan of care
- Personal care: care provided by home health aides such as helping you use the bathroom, dressing, and bathing when this is the only care you need
Before you start to receive HHS, the home health agency should discuss with you how much Medicare will pay and if there are any services or items which are not covered. You should also be provided with a Home Health Advance Beneficiary Notice (HHABN) before you are given services and supplies which are not covered by Medicare. Those on a fixed income can get financial assistance from Medicaid. Eligibility varies by state, but is generally based on income and assets, also known as resources. To receive Medicaid assistance for a nursing home stay, the patient must be in an approved facility. Medicaid will not pay for a private room unless it is medically necessary.
Financial help for nursing home costs may also be available to you through other channels, such as through an employer group health plan or long-term care insurance. Many of these plans require a lengthy term of enrollment before they will pay for a nursing home. For military veterans, the Veterans Administration Aid and Attendance benefit program may provide about $1,700 per month to offset your nursing home bills.
Medicare offers counseling to its enrollees regarding options on how to afford different types of long term care and what exactly will and won’t be covered under your existing plan. Additionally, Medicare.gov offers a tool which helps Medicare beneficiaries and their caregivers compare over 17,000 nursing homes nationwide. Characteristics which you can compare include the type of ownership, whether the home participates in Medicaid, Medicare, or both, and the number of beds in the home. A link to this tool as well as other informative links can be found by clicking here.