Paying for Long-Term Care

• The person needing care has Medicare Part A (also referred to as Hospital Insurance);
• There are remaining days in the beneficiary’s ‘benefit period’ or the beneficiary is eligible to begin a new benefit period;
• The person needing care has been an inpatient in the hospital for 3 or more days in a row. The count of days begins on the day the person is admitted into the hospital as an inpatient and ends the day before the person is discharged. The actual day that the person is discharged does not count as part of this 3 or more days hospital stay requirement.
• The person is in need of reasonable and necessary skilled care for the medical condition for which they were treated in the hospital;
• The person needing care enters a Medicare-certified skilled nursing facility immediately from the hospital or within 30 days of having been hospitalized;
• A doctor orders skilled services for the person needing care. Skilled services are those specific services that need professional skills to be provided, such as the services requiring care by nurses or therapists; and
• The skilled care services ordered by the doctor are needed daily. (Note: if the person needing care is in a skilled nursing facility for rehabilitation services, care is considered daily even if only offered 5 or 6 days each week.)

Medicare Part A coverage of skilled care in a Medicare certified skilled nursing facility is limited to 100 days and only the first 20 days are covered in full by Medicare. Here is how it works:

• • For days 1-20: Medicare Part A pays the full cost.

• • For days 21-100: Medicare Part A pays a certain amount and the person needing care is responsible for a daily co-payment unless they have a Medigap policy or Long Term Care Insurance that will pay this co-pay amount.

• • For days 100 and beyond: Medicare Part A pays nothing and the person needing care is responsible for the full cost out of pocket or through their supplemental insurance.

If someone needs care in a skilled nursing facility (like rehab in a nursing home), Medicare will only help pay if the person was officially admitted to the hospital as an inpatient for at least 3 full days in a row before going to the nursing home.

Here’s the catch: Some people stay in the hospital and receive care but are listed as being there for “observation” instead of being officially admitted. This is called Outpatient status, even though they’re in a hospital bed and getting treatment. Many patients don’t realize this difference.

If someone is under Observation (Outpatient) status, Medicare will not pay for:

• • The hospital stay itself (under Part A)

• • Medications given during the stay

• • Care or rehab in a nursing home after discharge

Always ask the hospital if the stay is considered Inpatient or Outpatient. It makes a big difference in what Medicare will cover.

Sometimes a nursing home may say that therapy has to stop because the resident has “plateaued,” meaning they’re not getting better. But Medicare can still cover therapy if it helps the person maintain their current abilities or slow down decline, even if they’re not improving.

If the nursing home says Medicare won’t pay anymore:

• • Ask for a “Demand Bill.” This means the facility will bill Medicare anyway, and Medicare will make the final decision.

• • Be aware: If Medicare says no, the resident might have to pay for those therapy services.

• • Talk to the resident’s doctor and therapist to see if therapy is still helpful.

• • Center for Medicare Advocacy, Inc. – A national non-profit group with a special focus on Medicare beneficiaries and their needs.

• • Medicare Rights Center – A national, nonprofit service organization focused on access to quality care for elders and individuals with disabilities that provides counseling, advocacy, and educational programs.

• • 1-800-MEDICARE official phone number for the Medicare program in the United States.

• • Commence Health – Handles complaints and appeals concerning services paid for by Medicare (or call (888) 396-4646).