One of the biggest misconceptions about Medicare is that it provides long-term nursing home coverage. It doesn't.
Medicare covers only limited periods of inpatient care, only in a skilled nursing or rehabilitation facility following a hospital stay, and only under strict guidelines. Still, Medicare nursing home coverage can be vital if the person you're caring for has just been hospitalized. Medicare can pay for costly short-term, intensive rehabilitation, which in turn can give you a chance to arrange for longer-term care if it's needed.
Medicare or Medicaid?
One of the reasons many people mistakenly believe that Medicare covers long-term custodial care is that they confuse Medicare with Medicaid, which is a completely separate program only available to people who have very low income and few assets other than their home. Unlike Medicare, Medicaid can cover long-term care, either in a nursing home or at home.
Who's eligible for Medicare nursing home coverage?
Medicare nursing home coverage is a standard part of Medicare Part A. Anyone enrolled in Medicare Part A can receive Medicare nursing home coverage if they qualify for it. There's no special paperwork needed to apply for Medicare nursing home coverage; the nursing home itself handles all the administration.
If the person you're caring for is enrolled in a Medicare Part C Medicare Advantage plan, it too will cover nursing home care, at least to the same extent (described below) as Medicare Part A does, and perhaps with somewhat broader coverage. Contact the plan directly to find out the exact terms of its nursing home coverage.
What kind of nursing home care does Medicare cover?
The term nursing home can refer to different types of places, including rest homes, nursing homes, board-and-care homes, assisted-living facilities, congregate living homes, and sheltered care homes. All of these provide what's called custodial care, which is long-term residence and nonmedical assistance with the activities of daily living -- such as bathing, eating, walking, and dressing -- for people who don't have acute medical conditions but who are no longer able to care for themselves completely. This type of custodial long-term care is not covered by Medicare.
At the other end of the nursing home spectrum is high-level inpatient medical care, referred to as skilled nursing or rehabilitation care. Under certain circumstances, Medicare Part A covers this skilled care for a limited time while a patient is recovering from a serious illness, condition, or injury. For Medicare to cover this care, it must be provided in the skilled nursing facility wing of a hospital, in a stand-alone skilled nursing or rehabilitation facility, or in the skilled nursing or rehabilitation part of a "multilevel" facility.
How does someone qualify for nursing home coverage by Medicare?
In order for someone to receive nursing home coverage by Medicare, a number of different conditions have to be met:
Prior hospital stay: A patient's stay in a skilled nursing or rehabilitation facility has to begin within 30 days of an inpatient hospital stay of at least three days (not including the day of discharge).
Need for daily skilled nursing or rehabilitation: Medicare provides nursing home coverage only if the patient needs, and his or her physician prescribes, daily skilled nursing care or physical rehabilitation. For someone who needs skilled care but doesn't need it every day, Medicare won't cover nursing home care. However, in that situation Medicare might cover home care.
Medicare-approved facility: For Medicare to cover inpatient skilled nursing or rehabilitation care, the care must be received in a facility that Medicare has certified for that purpose.
Improving condition: Medicare covers nursing home care only as long as the patient's condition is improving. Once Medicare, the patient's doctor, and the facility have determined that his or her condition has stabilized, Medicare will no longer cover inpatient nursing home care.
How much does Medicare pay for a skilled nursing home care?
If a patient meets the qualifying conditions for Medicare coverage of nursing home care, Medicare will pay only a limited amount for it.
For the first 20 days in a facility, Medicare pays all covered charges -- excluding items such as a telephone or television, or a private room if it's not medically necessary.
For days 21 to 100 in a nursing facility during any one benefit period, Medicare pays all covered charges except a daily "coinsurance amount" for which patients are personally responsible. In 2012, that amount is $144.50 per day. If the patient has a private Medigap supplemental insurance policy, that policy might pay some or all of this coinsurance amount.
After 100 days in a covered skilled nursing facility in any one benefit period, Medicare no longer pays any of the cost.
If the patient is enrolled in a Medicare Part C Medicare Advantage plan, the plan may provide broader coverage than Medicare Part A does. Contact the plan directly to find out what its nursing home coverage and payment terms are.
Where can I get more information about Medicare coverage for nursing facility care?
If the person you're caring for is in the hospital and you're looking for answers about follow-up nursing-facility care, contact the hospital's discharge planner, who can arrange this type of care, or the hospital ombudsman, who's trained in Medicare issues and helps patients understand them.
You can also get information about Medicare nursing home coverage directly from Medicare's website or by calling (800) 633-4227. If the person you're caring for has already been referred to a particular nursing facility, the intake administrator for that facility can also help with Medicare-related questions or problems.