Medicare never covers the full cost of a skilled nursing facility. Medicare does not always provide 100 days of rehabilitation, it will pay “up to” 100 days. Medicare Part A covers the full cost of the first 20 days in a rehabilitation facility when a patient meets certain qualifications after a hospital stay. For days 21-100, there is a co-pay of $194.50 per day – if the patient continues to need rehabilitation services during that period. After Medicare stops paying, the full cost of the nursing home falls on the patient. This can cost upwards of $600 per day.
Qualifying for Medicare Part A Coverage
Medicare Part A covers the rehabilitation stay so long as certain prerequisites are met:
(1) the admission to the facility is within 30 days of the date of the hospital discharge;
(2) the prior hospitalization must be for at least three consecutive days, excluding the day of discharge;
(3) the doctor concludes the patient needs daily skilled nursing care or rehabilitative services; and
(4) the medical condition relates to the condition treated by the hospital during the qualifying 3-day inpatient hospital stay.
Qualifying Hospital Stay
The Medicare program is difficult to navigate because of the nuances of coverage. It is important to inquire from hospital staff whether the patient was “admitted” to the hospital or was merely under “observation.” 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 is only available in a skilled nursing facility.
Days 21 – 100 – Skilled vs Custodial Care
Coverage for rehabilitation under Medicare Part A is intended to be short-term. The goal is improvement of acute conditions through rehabilitation and skilled nursing care. As mentioned, the first 20 days in the rehabilitation facility are covered in full by Medicare. Some Medigap/Supplemental co-insurance policies will cover all or part of the $194.50 daily co-pay for days 21-100. But patients rarely qualify for 100 days of rehabilitation. After admittance to a facility, the patient is evaluated periodically. Once the facility determines that the patient no longer needs skilled care, coverage under the Medicare program ends. The most important piece to understand is the difference between killed care and custodial care. Medicare does not cover custodial care.
Skilled nursing care includes nursing and therapy care that can only be performed by registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists. Custodial care is help with activities of daily living, such as getting in and out of bed, eating, bathing, dressing, toileting and grooming. Custodial care is traditionally provided in a nursing home.
There are many circumstances where the patient does not fall into the category of needing rehabilitative or skilled care, but the family cannot bring their loved one home safely. Medicare does not pay for time to set up a discharge plan. Once Medicare terminates coverage, the patient needs to return to the community or start privately paying for care.
A patient can qualify for a new 100 day benefit period only after being out of a hospital or skilled nursing facility for 60 days in a row. It is a prevalent myth that Medicare pays for long term care in a nursing home. The only government program that pays for long term care in a skilled nursing facility is the Chronic Medicaid program. It may be necessary to speak with an elder law attorney in your area to get information about your specific case.