What is meant by "medically neccessary" or under what circumstances will Medicare pay for long-term care?

2 answers | Last updated: Mar 11, 2013
Julepalm asked...

What is meant by "medically necessary" or under what circumstances will Medicare pay for long-term care?

Expert Answers

Basically, Medicare covers only a short time of long-term care, and only under very strict rules. Medicare Part A can cover most of the cost of a rehabilitation stay in a skilled nursing facility, but only for a certain number of days following a hospital stay, and only for skilled nursing care. Medicare Part A or B can cover home care, but only for a limited time, until the patient is stable, while someone recovers from an illness or injury. Medicare does not cover open-ended home care or residence in a nursing home. The article on this site called Medicare and Long-Term Care: What’s Covered, What’s Not explains in detail the rules regarding Medicare coverage of nursing facility and home care. But here is a short explanation of the coverages.

To get Medicare Part A coverage for nursing facility care, it has to begin within 30 days of an inpatient hospital stay of at least three days. It is covered only if medically necessary, which means the patient needs, and the doctor prescribes, daily skilled nursing care or physical rehabilitation. It has to be provided in a Medicare-certified skilled nursing facility. And Medicare covers inpatient skilled nursing care only as long as the patient’s condition is improving. Once Medicare, the doctor, and the facility decide that the patient’s condition has stabilized, Medicare will no longer cover inpatient care.

If these conditions are met, for the first 20 days in the facility Medicare pays all covered charges. For days 21 to 100 during any one benefit period, Medicare pays all covered charges except a daily "coinsurance amount" for which the patient is personally responsible. In 2008, that amount is $128 per day. If the patient is part of a Medicare Part C managed care plan or has a private medigap supplemental insurance policy, that plan or policy might pay some or all of this coinsurance amount. After 100 days in a covered nursing facility in any one benefit period, Medicare no longer pays any of the cost.

Medicare can also cover nursing care and physical and speech therapy while a patient recovers at home from an illness or injury. Medicare also covers needed medical supplies and equipment. As part of this home care, though, Medicare does not generally cover nonmedical care and assistance, including meals and housekeeping. However, if a patient gets Medicare coverage for home care, it can pay for limited visits by the home care agency to help with personal care.

For Medicare to cover home health care, the patient must have a medical need for, and a doctor must prescribe, skilled nursing care or rehabilitative physical or speech therapy. The care must be part-time only, to help recover from a specific illness, injury, or acute condition. Medicare does not cover full-time or daily care. To get Medicare home care coverage, the patient must be confined to home, meaning unable to leave home without difficulty and requiring the assistance of another person or a medical device such as a wheelchair. The care is covered only while the patient is actively recovering. Once the patieent’s condition has stabilized, coverage ends. Also, care must come from a Medicare-certified home healthcare agency.

If a patient qualifies for home care coverage, Medicare pays the full amount of the agency charges. There is no specific limit on the number of home care visits Medicare will cover, but coverage continues only as long as the patient meets all of the strict qualifying conditions for coverage. The condition and needs of the patient are regularly evaluated by the agency and by Medicare to determine how long the care is medically needed.


Community Answers

Pdavis712 answered...

My doctor stated that i needed a caregiver to live=in and help me cause the medical condition i have is worsen daily? I would like to know how would i go about applying for this? Hiring the person i want to stay with me to help me go to doctor and take care of me while i am in sever pain. I am disable on Medicare and Medicaid what do i do? I need to know ASAP