The Basics of Medicare Coverage for Nursing Home Care

Are you confused about using a Medicare plan to help offset the cost of nursing home care? If so, you’re not alone, as the topic is rife with details and technicality. In this article, we cover what kind of nursing home care services you can expect to be covered by Medicare, and which will not.

The Relationship Between Medicare Coverage and Nursing Home Care

Estimates say that over half of all nursing home residents are senior citizens over the age of 85, with relatively few being younger than 65 years old. The vast majority of those senior citizens are also enrolled in Medicare. Around-the-clock nursing home care can also be quite expensive, with average monthly costs running up to $10,000 or beyond.

It is no wonder that those most likely to be in need of nursing home care may wish to turn to Medicare plans to offset such a cost burden. Similarly, senior citizens who already rely on Medicare may be contemplating enrolling in a costly nursing home. They may need to know whether their coverage extends to nursing home care before making a decision.

While you may hear that Medicare plans do not cover the costs of nursing home care, the full picture is more complicated.  You may still have some viable options and it can depend on your Medicare plan and particular nursing care needs.

The Different Kinds of Medicare Coverage

To best understand how Medicare can work with nursing home care, it is important to first understand the purposes of each type of plan in the Medicare alphabet. Do keep in mind that the exact details of Medicare coverage vary by state. As a result, you should always contact your doctor or healthcare provider for the most up-to-date and accurate coverage policies in your area.

Medicare Part A

Also known as “hospital insurance,” Medicare Part A is the principal component of Medicare and covers services like inpatient hospital care, home healthcare, and hospice care. More on this in relation to nursing care will be discussed later. For now it is worthwhile to mention that “skilled nursing facility care” is specifically mentioned in eligible coverage. However, this does not include custodial or long-term nursing care.

Medicare Part B

An optional component of what is referred to as Original Medicare, Medicare Part B is designed to serve as “medical insurance”. It covers medically necessary services like ambulance trips and outpatient care. Part B has little direct relevance to nursing home care. However, it still covers all applicable medical services that may be required outside of the nursing facility.

Medicare Part C

Unlike Part A and Part B, Medicare Part C plans are offered by private insurance companies and are only approved by Medicare. You may have heard Part C plans referred to as Medicare Advantage or Medicare Health. These plans do not usually provide nursing home care coverage outside the legal requirement that they provide the same minimum coverage as Parts A and B. However, it is worth checking with your local provider directly if you happen to already hold a Part C plan.

Medicare Part D

The most recent addition to the Medicare stable, the optional Part D offers prescription drug coverage. Part D plans can be purchased from private insurance companies and contract directly with established long-term care facilities. If you are thinking of entering a nursing home facility with its own pharmacy, be sure to choose a Medicare Part D plan that has a contract like this already in place.

Medicare for Custodial or “Non-Skilled” Personal Care

It is important to note that Medicare Part A explicitly does not cover custodial care. Custodial care is defined as “non-skilled personal care” and involves help with such necessities as eating, bathing, and dressing. It is often long-term by nature and designed to provide assistance for those who are otherwise not able to take care of their own daily living needs.

Assisted living facilities are a common example of long-term nursing home care. This means that, by and large, living assistance provided at such facilities is not covered by Medicare. With that said, Medicare Part D plan holders may still receive coverage for necessary prescription drugs. Ensure the contract is in place between the nursing home pharmacy and the provider of the Part D plan.

Medicare for Skilled Nursing Care

Medicare Part A does provide coverage for certain instances of care received at a skilled nursing facility (SNF). Skilled nursing care is overseen by specialists who are trained to provide rehabilitation and care for those suffering from serious illnesses. Skilled nursing care usually involves medically necessary assistance. This includes help with IV tubes, physical therapy, and treatment for open wounds.

Such skilled nursing care may be eligible for Medicare coverage as long as a number of criteria are met. The most important criteria include the following:

• You must be enrolled in Medicare Part A

• You must have a “qualifying hospital stay” of at least three consecutive days prior to admittance into an SNF

• Arrival at the SNF should be soon after the qualifying hospital stay. A 30 day window is a good rule of thumb

• Your doctor should prescribe the nursing home care based on his or her analysis of your situation

• The chosen nursing home is certified by Medicare

SNF Costs under Medicare

Assuming the SNF care you require meets the above requirements, know that Medicare will only provide coverage on a short-term basis. As a result, the costs incurred will vary depending on the length of care.

Medicare Part A covers all costs of SNF care incurred in the first 20 days of a given benefit period. From days 20 to 100, the costs jump to $170.50 per day in coinsurance. Medicare coverage stops on day 101, as the care is now long-term and falls outside the scope of Part A.

What Happens If You Need Long-Term Care but Can’t Pay?

If you require long-term care but lack the means to pay for it, Medicaid serves as another coverage option. Medicaid is intended to provide coverage for those who don’t have the means to pay for necessary treatments. There are many federal and state guidelines for eligibility and nursing home coverage is evaluated separately at the state level. However, it is worth considering if applying for Medicaid is the right solution for you.

Conclusion

We hope this has provided a useful overview concerning the ins and outs of using Medicare for nursing home care. There are many details to keep in mind, but to recap as simply as possible:

• Long-term or custodial nursing care is not covered by Medicare Part A. However, short-term care provided in a Skilled Nursing Facility (SNF) may be eligible after meeting certain requirements.

• Medicare Part D can be used to offset prescription drug costs while staying in a nursing home.

• Medicaid may be able to provide coverage for long-term care where Medicare Part A does not.

It's always good to consult a doctor or health professional for guidance on what is and is not covered in your area. Medicare is provided at a state level and local providers have different criteria for eligibility. Consulting a professional with localized knowledge is vital.