The majority of people in the United States are familiar with “Medicare” and “Medicaid” by name, however, many are unable to tell you the difference between the programs. The next two posts will give you a brief overview of Medicare and Medicaid in a nursing home setting to become better informed and to learn about your options.
Medicare is a federal health insurance program which provides coverage for individuals over the age of 65 and people under 65 who are disabled. Medicare comes in four parts, Parts A, B, C, and D. As an elder law attorney, I most frequently counsel clients about Medicare Part A - coverage in a skilled nursing facility or SNF.
Medicare Part A covers up to 100 days of “skilled nursing” care per spell of illness. A patient discharged to a skilled nursing facility can receive up to 100 days of skilled nursing care, which most importantly, includes speech, occupational and physical therapy.
The conditions to qualify for these 100 days are strict so it is important to know the rules. The main requirements are:
The Medicare recipient must enter the skilled nursing facility no more than 30 days after a hospital stay which lasted for at least three days, not counting the day of discharge. This is sometimes referred to as “three overnights” in the hospital to be eligible. Important: You must be in the hospital as an inpatient. “Observation status” does not count. In my practice, I often see clients who did not know they were not inpatient and then are denied Medicare Part A coverage.
A physician certifies that the patient needs care in a skilled nursing facility;
The patient must go to a facility that is Medicare certified; and
The patient needs the skilled services for a medical condition that is either:
A hospital-related medical condition treated during your 3-day inpatient hospitalization (even if different from reason you were admitted to the hospital); or
A condition that started while you were getting care in the nursing home for a hospital-related medical condition.
Medicare Part A coverage can be ended by the facility as soon as the skilled nursing facility determines the individual no longer needs skilled nursing care. For residents, this means an end to coverage at the skilled nursing facility and possibly a lost chance to rehabilitate and go back home. In my practice, I often counsel clients on how these decisions are made and how they can be appealed when they are unfair.
This post is meant to give you basic information about Medicare coverage in a skilled nursing facility. Yet, there are many more nuances that are not included here. If you have questions about Medicare or coverage in a skilled nursing facility, please contact Attorney Lauren Kaplan at lkaplan@curlerlaw.com or (312) 952-1077 for a free consultation.
The contents of this blog post are intended to convey general information only and not to provide legal advice or opinions.