Get the Most Out of Medicare’s Nursing Home Coverage | Print |  E-mail
Wednesday, 21 November 2012 13:51

Medicare will cover 100 days of skilled nursing care, but only after 3 full days of hospitalization

112212senBY GENE L. OSOFSKY, ESQ.

Special to the Times

Q: My wife and I do not have long-term care insurance. We hear that Medicare coverage for nursing homes is limited. Do you have any tips on how to make the most of it?



A: Medicare coverage for nursing home stays is really designed for short-term convalescence following a hospital stay. But if you know the rules, you can get the most out of this limited coverage.

Basic rule

Medicare will only cover up to 100 days in a nursing home, but only after a 3-day hospital stay. Days 1-20 are covered 100 percent. Days 21-100 would have a patient co-pay of $144.50 per day (unless you have a Medicare Supplement Plan).

If you qualify, Medicare would cover care at a nursing home, which is technically called a skilled nursing facility (“SNF”). However, it does not cover the cost of your residence at assisted-living facilities.

The 3 Day Hospital Stay

To trigger coverage, you must have been first admitted into a hospital for at least 3 days. Thus, direct entry from home to the SNF will generally not qualify.   

Tip: If SNF care appears likely after discharge, consider going to the SNF directly upon hospital discharge, or at least within 30 days of discharge. Note: if you are enrolled in a Medicare Advantage Plan, a prior 3-day hospital stay may not be required. Check your plan.

The “Observation Status” Trap

If you go to the emergency room and are maintained in “observation status,” that time period does not count toward the 3-day requirement. You must actually have been “admitted” into the hospital.

Unbeknownst to them, patients are sometimes kept in observation status for days.

Tip: If it appears that you may need follow-up care in a SNF, check your hospital status and make sure you have been formally “admitted.”

The “3 Midnights Rule”

The 3 days are counted by reference to stays past midnight of each qualifying day.

Example: If you are admitted on Monday at 11:50 p.m. and discharged on Wednesday evening at 8 p.m., you will have not met the 3-day requirement. But if you’re not discharged until Thursday morning at 8 a.m., you will have met the requirement.

Tip: If you believe you are about to be discharged before the third midnight, ask your doctor to extend your stay if otherwise medically justified. Sometimes just a few hours can secure coverage.

Must Need Skilled Therapy

In order to receive the full 100 days, you must need skilled medical therapy on a daily basis, e.g. wound care, intubation or rehabilitation.

If you only need help with activities like bathing, toileting or eating (“custodial care”), you will not qualify for Medicare coverage even if you have not used up your full 100 days.

Tip: Make sure you request and fully cooperate with prescribed skilled therapies while in the SNF.

“Medical Improvement Standard” Often Misapplied:

If you hear the SNF staff describe your Medicare days as ending because your improvement has “plateaued,” they are likely applying an incorrect standard. Medical improvement is no longer required.

The correct standard is whether ongoing therapies in the SNF are needed to help you to “attain” or “maintain” your highest level of function, i.e. to help you avoid “back sliding.”

Tip: Ask your therapists and/or physician if you would be at risk of losing functionality if therapies were stopped and, if so, ask them to note that in your chart.

Expedited Appeal:

If you receive a notice that your benefits are about to be terminated before the 100 days, request an appeal. Appeals are decided by an outside agency, are often resolved in one day, and many are won.

Tip: Make sure your medical chart contains a statement by the medical providers that continued therapies are necessary to help you “maintain” your highest level of function.

Knowledge of the rules and patient advocacy can go a long way toward ensuring full Medicare coverage. However, extended stays will require private pay or application for a Medi-Cal subsidy.

Gene L. Osofsky is an elder law and estate planning attorney in Hayward.  Visit his website at www.LawyerForSeniors.com.

 

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