Question: My mom fell in her home and is being discharged from the hospital to a nursing home for rehabilitation. A friend told me that Medicare will pay for Nursing Home Care, is this true?
Answer: Long Term Nursing Home care is not part of the Medicare program. However, when someone is being discharged from the hospital to a skilled nursing facility for the purpose of receiving skilled or rehabilitative services, the stay will be covered under Medicare Part A so long as certain pre-requisites are met. The prior hospitalization must be for at least three consecutive days, excluding the day of discharge, and the admission to the facility must be within thirty days of the date of the hospital discharge. It is important to inquire from hospital staff whether the patient was admitted to the hospital or was merely under “observation” because observation status days do not count towards the three day minimum. It is also necessary that the patient require either skilled nursing or rehabilitative care on a daily basis, and that the care being provided can only be provided in a skilled nursing facility.
Coverage for rehabilitation services under Medicare Part A is limited and is intended to be short-term coverage for acute conditions with the goal of improving that condition through rehabilitation and administration of skilled nursing care. The first 20 days in the rehabilitation facility are covered in full by Medicare. For days 21-100, there is a co-pay of $157.50 per day. Some Medigap/Supplemental co-insurance policies will cover all or part of the co-pay. Note that Medicare does not always provide 100 days of rehabilitation, it will pay “up to” 100 days. After admittance to a rehabilitation facility, the patient will be evaluated periodically. Once a determination has been made that the patient no longer has a skilled need, coverage under the Medicare program will terminate. Medicare uses a “maintenance standard” to determine an appropriate discharge date. This means that if the patient’s condition could not be maintained without the rehabilitation services, they can Medicare will continue this benefit. The relevant question is not: has the patient plateaued? But rather: would the patient’s condition decline if the services were terminated? Oftentimes family members believe this determination has been made prematurely. If the patient or their representative believes the determination is incorrect, they can appeal. A patient’s appeal rights should be presented to them upon admittance to the facility as well as in the notice of discharge.
Navigating the Medicare system can be difficult. Consulting with an elder law attorney upon hospital discharge or skilled nursing or rehabilitation facility admittance can provide you with the tools necessary to ensure the most productive rehabilitation process. If your mom needs long term care at home or in a nursing home, Medicaid could be an option.