Nursing Homes and Using Your Medicare Plan

Understanding your Medicare benefits when it comes to nursing home care is important because there are limitations on what your coverage can be used for. In general, Medicare does not cover the daily expenses of long-term care you receive in a nursing home, though there are some nursing facilities where your coverage can provide temporary benefits.

While Medicare does offer some help for individuals who receive short-term care from nursing facilities and homes, the kinds of care you need and for how long largely impact how much you will end up paying out of pocket. Medicare will not pay the daily cost of living in a nursing home, but it will pay for 100 days of care in a nursing or rehabilitation facility to help you become independent again.

To determine if Medicare will help cover some of your costs, you should know that Medicare categorizes nursing facilities two ways: as providers of either skilled nursing care or custodial care. People often seek out these kinds of nursing centers for different reasons and needs, and how Medicare will cover your nursing home expenses depending on which kind of care you are receiving.

Some Coverage With Skilled Nursing Care

Skilled Nursing Care is just what it sounds like: care you get from a skilled healthcare professional. This kind of health assistance can take place in a hospital or nursing home, but requires a doctor, nurse or therapist to treat and evaluate your recovery. Some people required skilled nursing care after injuries, major surgeries, stroke or illnesses that require help from a healthcare professional like a physical therapist, speech pathologists or licensed nurse. These health practitioners may provide services like physical therapy, intravenous injections, creating a care plan, changing bandages and observing your condition — care that only a licensed professional can provide.

In most cases, skilled nursing or therapy is necessary to improve your situation or prevent it from worsening. Most people utilizing skilled nursing care have had a recent hospital stay for their health condition — in fact, you must have stayed in a hospital for at least three days before Medicare will cover your skilled nursing care. The end goal is for you to return home in steady condition with a strong start to recovery.

Skilled nursing care is different from custodial care (assistance with everyday tasks) because it is expected to be short-term care. According to the Centers for Medicare & Medicaid Services, most people who get skilled nursing care leave the facility before they are fully recovered, often because Medicare provides coverage for only 100 days and the recovery process can be completed from home. So long as you meet certain requirements, Medicare will cover your stay in a skilled nursing facility.

No Coverage With Custodial Care

Custodial care is different from skilled nursing care because in most cases, it is used for a longer period of time. Custodial care is what many residents in nursing homes require – help with typical daily activities that they can no longer perform on their own, such as bathing, getting dressed or preparing meals. It can also extend to requiring oxygen or help with catheters. This kind of care is often related to aging or the permanent effects of an injury, illness or health condition.

Custodial care is often provided in-home or at a nursing home and can be offered by a friend, family member or professional. But if custodial care is the only type of assistance you need, Medicare benefits will not cover the expense and you will be responsible for the full cost of this kind of help.

How to Qualify For Coverage in Skilled Nursing Care Facility

As we explained above, custodial care does not qualify for Medicare coverage. Unfortunately, that means your daily expenses of living in a nursing home — things like room and board and food costs — will be out-of-pocket expenses. But if a recent illness or health condition requires additional care outside of a hospital at an in-patient facility, you can likely qualify for skilled nursing care coverage. To qualify:

  • You must be enrolled in Medicare Part A (hospital insurance)
  • You must have been admitted to a hospital for three or more consecutive days and enter the skilled nursing facility within 30 days of leaving the hospital
  • Your doctor must request you receive skilled nursing facility care

If your skilled nursing care qualifies for coverage, Medicare will help cover the cost of services such as:

  • A semi-private room shared with another patient
  • Meals
  • Medical attention and care
  • Physical, occupational and speech therapy
  • Medications
  • Medical supplies and equipment you may need
  • Ambulance transport services
  • Dietary counseling

Even if you qualify for coverage, it is important to know that Medicare will gradually reduce the amount of assistance in covering your nursing facility stay. For the first 20 days you will pay nothing with Medicare shoulders the cost. But after 100 days in a nursing facility, you will be responsible for the total cost of your care. If you have a Medicare Advantage or supplemental insurance plan, your policy may help cover additional costs after Medicare quits paying.

Covering the Cost of Nursing Home Care

If you’re considering dropping your Medicare coverage because you think it will not be beneficial in a nursing home for custodial care, you may want to reconsider. There are still perks to having Medicare benefits even if you are responsible for the day-to-day costs of nursing home care, such as room and board. Your Medicare coverage can still be used for health expenses, just like when living outside of a nursing home. With Original Medicare Parts A and B, you will still have hospital insurance and doctor’s office coverage, allowing you to get treatment if an emergency happens or health condition worsens. Individuals who opt into a Medicare Drug plan (Part D) can also get assistance with medications, and if you have a Medicare Advantage plan, a private insurance provider may offer you vision and dental benefits.

Paying for nursing home care — both skilled care and custodial care — can be costly regardless of what kind of plan you have. In some cases, long-term care insurance can help relieve some of the burden. The Medicare Specialists at PolicyZip are well-versed in helping seniors find coverage for a variety of needs.  Call (844) 627-7700 to speak with a specialist or fill out the form below.