Medicare coverage for nursing home care

If a patient has spent 3 days in the hospital, Medicare may pay for care in a Skilled Nursing Facility:
imageDays 1 – 20: $ zero co pay for each benefit period
Days 21 - 100: patient pays $164.50 coinsurance per day during 2017
image Days 101 and beyond: patient pays all costs

Do you know your rights to nursing home coverage under Medicare? Medicare Part A pays for inpatient hospital care, and then for care in a skilled nursing facility IF the patient has a "qualified" hospital stay of at least 3 days (not counting day of discharge) before being admitted to the skilled nursing facility.

In a February 2, 2017 decision, the federal judge overseeing the Medicare "Improvement Standard" case (Jimmo v. Burwell) ordered the Secretary of Health & Human Services to make it possible for nursing homes to comply with the Settlement, so discharged hospital patients can get rehabilitation.

If you go to the nursing home following a hospital stay, nursing homes are often reluctant to keep billing Medicare, because they think Medicare coverage depends on beneficiary’s restoration potential; but the standard is whether skilled care is required:

PDF Summary. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. The nursing home patient who needs these skilled services should still be covered by Medicare.

The February 16, 2017 statement by Centers for Medicare & Medicaid Services (CMS) says: "Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided."

"Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program."

Patients who were put on Observation Status in the hospital end up paying out-of-pocket if they need nursing home care:


PDF Summary. Readers Digest Artilce on advocacy at time of hospital discharge. Medicare is telling hospitals to keep patients "under observation," to prevent eligibility for the 100 days of Skilled Nursing Facility benefits. A Medicare fact sheet warns patients to ask about their status when they are in the hospital: "You’re an inpatient starting the day you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day." Medicare patients are bouncing in and out of hospitals because of this Medicare "bookkeeping change"

US CapitolCongress voted to require hospitals to tell Medicare patients when they are under observation care and have not been admitted to the hospital. The NOTICE law requires hospitals to provide written notification to patients 24 hours after receivinMassachusetts mapg observation care, explaining that they have not been admitted to the hospital, the reasons why. The Notice must also disclose the financial implications for cost-sharing in the hospital and the patient's subsequent “eligibility for coverage” in a skilled nursing facility (SNF).

But Medicare has been "Mooning" patients. Hospital reimbursement rules that were published in the Federal Register on August 2, 2016 by the Centers for Medicare & Medicaid Services (CMS) says that the NOTICE law becomes effective October 1, 2016 but the written notice to patients – the Medicare Outpatient Observation Notice (MOON) – will not become effective until 90 days following approval of the MOON by the Office of Management and Budget (OMB). As of August 4, OMB had not approved the MOON. So the NOTICE Act will not be implemented until the late Fall of 2016, at the earliest. articleHospital Observation Status can be financially devastating. Read More by Attorney John L. Roberts at: "This happened to us last year. After 4 days we were told the status was changing to outpatient." More in Reader Comments.

Getting Medicare to pay for skilled nursing home care.
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