Medicare Nursing Home Coverage

Today, due in large part to advances in medical technology, people are living longer than ever before. While this is good news, it does not necessarily mean that people are living those extra years in a healthier state – and because of this, many will require long-term care.

In 2013, the average annual cost of a semi-private room in a skilled nursing home exceeded $80,000 in the U.S. Unfortunately, regular health insurance policies do not cover these costs, and Medicare covers very little.

What Type of Nursing Home Coverage Does Medicare Cover?

Medicare Part B covers some services for expenses that are incurred in a skilled nursing home facility. This coverage, however, is somewhat limited. The coverage includes the cost of a semi-private room, as well as meals, skilled nursing services, rehabilitative services, and certain other medically necessary services and supplies.

These costs are only covered, however, if the Medicare enrollee meets certain criteria. It is important to note that while Medicare covers some types of skilled care, it does not cover long-term care or custodial care.

How Do You Qualify for Medicare Coverage in a Skilled Nursing Home?

In order to qualify for Medicare’s coverage in a skilled nursing home, you must meet several criteria. These include:

  • You must have been in the hospital for a minimum of three days, not including the day of discharge, for a medically necessary reason that was directly related to the illness or injury in which you are in the skilled nursing facility
  • You must be admitted to a Medicare-certified skilled nursing home facility within 30 days of your previous hospital stay
  • You must be certified by your doctor or medical professional as needing skilled daily care such as physical therapy or intravenous injections

How Much Does Medicare Cover for Skilled Nursing Home Coverage?

Provided that you meet the criteria to receive Medicare benefits for skilled nursing facility coverage, you will be subject to certain copayments for the coverage that is received, depending on how long you remain in the skilled nursing facility.

Medicare’s skilled nursing home benefits are as follows (for 2014):

  • For days 1 through 20, you pay nothing
  • For days 21 through 100, you are required to pay a daily copayment of $152
  • For any days after day 100, you are required to pay all costs

These copayments are on a per-benefit period basis. This means that if you leave the skilled nursing home and then re-enter it, you may be required to pay these copayment amounts again if you have entered a new benefit period.

Other Medicare Covered Long Term Care Services

In addition to skilled nursing home facility coverage, Medicare may pay a limited amount of coverage if your doctor or other health care professional states that certain services are medically necessary in order to treat an injury or illness. These services include:

  • Part-time or intermittent skilled nursing care
  • Occupational or physical therapy that is ordered by a doctor and that is provided by a Medicare-certified home health agency, and is only provided for a certain number of days
  • Speech-language pathology that is ordered by a doctor and that is provided by a Medicare-certified home health agency, and is only provided for a certain number of days
  • Medical social services in order to help in coping with psychological, social, medical, and / or cultural issues that are the result of an illness
  • Durable medical equipment and / or supplies such as a hospital bed, wheelchair, walker, and / or oxygen

There is time no limit on how long you can receive these services, provided that the services remain medically necessary, and provided that your doctor or health care professional continues to reorder such services for you every 60 days.

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