Medicare only covers the first 100 days of a nursing home stay (and only under certain conditions) – and there is a copay after the first 20 days.
Medicare covers a maximum of 100 days per spell of illness (explained below) in a nursing home (also known as a skilled nursing facility) and only if all the following requirements are met:
- The patient was admitted for a hospital stay of at least 3 consecutive days (3 consecutive midnights), not including the day of discharge;
- After which a physician certifies that
- The patient needs daily skilled care in a skilled nursing facility
- To which the patient is admitted within 30 days after discharge from the 3-day hospital stay
- For a condition the patient was treated for during the 3-consecutive day hospital stay or for a condition that arose while patient was in the skilled nursing facility (like a post-surgery infection).
This is really only intended to cover post-surgery rehab services like physical therapy, occupational therapy, or antibiotic infusions that must be provided by licensed medical personnel. It is not intended to and won’t cover long-term nursing home care or a person who only needs assistance with custodial care (activities of daily living like dressing, eating, showering, food preparation, house cleaning, etc.).
Copays per spell of illness:
Days 1-20 in the skilled nursing facility – the patient pays no copay.
Days 21-100 – co-pay of $200/day (in 2023, this number is adjusted annually and may be different in states other than Texas).
(So if the patient is in the skilled nursing facility for 100 days, the patient’s copay would be $16,000 unless they have long-term care or Medigap insurance to cover this.)
Days 101 and after – Medicare pays nothing so the patient has to pay the full cost if they don’t have long-term care insurance or Medigap insurance. So if it appears that the patient will require on-going nursing care and can’t afford the cost, they or their family will need to take steps early to qualify them for Medicaid for long-term care coverage.
To satisfy #3 above, the patient must be officially admitted to the hospital. Hospitals have been known to keep patients “for observation” overnight without officially admitting them. If the patient is “admitted” for two days after one day of observation, requirement #1 above will not be satisfied and Medicare will not cover the costs if he or she goes into a skilled nursing facility for treatment of the same condition within the next 30 days.
What is a “spell of illness”? It is the period of time from when a patient is first admitted into the hospital, continues through treatment at the hospital and then at the skilled nursing facility (rehab) and ends 60 days after the patient last leaves the skilled nursing facility. So between each “spell of illness” for which the patient seeks Medicare coverage, the patient must have spent at least 60 days not in a hospital or skilled nursing facility. You can have more than one “spell of illness” in a year (covered at least partially for 100 days by Medicare) – but there must be 60 days after the discharge for one before the start of the second one. If the patient returns to the skilled nursing facility before 60 days after discharge for the same condition, then it is considered the same spell of illness and is included in (and limited to) the same 100 days of coverage.
Medicare coverage for inpatient mental health care is even less generous, possibly because our brains, like our teeth, are apparently not considered parts of our bodies for medical purposes. But that is a rant for another day.
If you suspect that a family member is going to need long term nursing home care, then make sure they have adequate Medigap or long term insurance. If those are not affordable options, then focus on qualifying them for Medicaid. I will be posting about Medicaid more in the future.
Megan Baumer Estate Planning and Elder Law Attorney Law Office of Michael Baumer 512-476-8707 Website: www.baumerlaw.com/medicaid Blog: www.baumerestateplanning.com
