What are the Requirements for Medicare’s Skilled Nursing Home Coverage?

Although Medicare covers many services, the coverage that is provided for long-term care is not as extensive as some might think. In fact, there is a common misconception that Medicare will pick up most or all of the charges that one incurs in a nursing home facility or for long-term home health care. Unfortunately, this is not at all the case.

It is estimated that nationally, Medicare only covers about 5 percent of all nursing home costs – and the criteria that one must meet in order to qualify for that are quite stringent. What Medicare does cover in terms of skilled nursing home facility care is picked up under Medicare Part A.

In order to qualify to receive care in a skilled nursing home facility, a Medicare enrollee must meet all of the following:

• First, he or she must require daily “skilled care,” which as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
• The individual must also have been in the hospital for at least three consecutive days – not including the day of discharge – prior to entering the skilled nursing home facility that is certified by Medicare.
• In addition, the person must be admitted to the skilled nursing home facility for the same condition in which he or she was treated in the hospital, and they must be admitted to the nursing home within 30 days of being discharged from the hospital.
• The individual must also be certified by their physician or other medical professional as needing either skilled nursing or skilled rehabilitation services on a daily basis.

Should a Medicare enrollee meet all of the required criteria to enter a skilled nursing home facility and receive Medicare coverage, their benefits will be paid as follows:

• All of the approved charges for the first 20 days in the skilled nursing home facility will be paid in full by Medicare.
• After the 20th day, the patient will be responsible for paying a daily co-insurance amount. This amount in 2014 is $152.
• Should the patient require more than 100 days of care in the skilled nursing home facility, then he or she will be responsible for paying for the entire amount of their care, beginning with day 101.

In addition to covering limited skilled nursing home facility expenses, Medicare also covers some of the costs of receiving home health care. If an individual only needs assistance with basic daily activities, then Medicare will not typically cover such costs.

However, Medicare will cover the costs of medical care that is received in the patient’s home – which includes assistance with daily activities – should that be part of a doctor’s orders for the patient.

In order to receive home health care coverage from Medicare, the home care agency that is used must be approved by Medicare, and the patient must also meet certain qualifications based on their Medicare or Medicare Advantage Plan. Some of the services that may be included could encompass physical therapy, occupational therapy, and part-time nursing care.  Many services will require a copay but you can eliminate that with a medicare supplemental insurance policy that can fill the coverage gap with only a minimal monthly payment.