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Care Services in a Skilled Nursing Facility Covered by Medicare and Medicaid Amy Barlow

November 5th, 2012

MedicalCostsAccording to researchers at Mount Sinai School of Medicine, health-care costs during the last 5 years of life exceed patient’s total assets for 25 percent of the Medicare population. This is because although Medicare provides a significant amount of health care coverage, it does not cover co-payments, deductibles, homecare services, or non-rehabilitative nursing home care.

This shows just how important it is to ensure that patients make full use of their Medicare and Medicaid covered services. The care coverage in Skilled Nursing Facilities (SNF’s) varies between Medicare, Medicaid and private insurance. The task of sorting through various websites and insurance paperwork to figure out your eligibility for these services can be a challenging task.

Below we break down the eligibility requirements for Medicare and Medicaid coverage and the SNF services that are covered.

Medicare covers patients for SNF services if they meet all of the following conditions:

  1. They have Part A coverage and have days left in their benefit period;
  2. They have a qualifying hospital stay;
  3. Their doctor has decided that they need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff;
  4. They get these skilled services in a skilled nursing facility that is certified by Medicare;
  5. If their break in skilled care lasts for more than 30 days, they need a new 3-day hospital stay to qualify for additional SKILLED NURSING FACILITY care. The new hospital stay doesn’t need to be for the same condition that they were treated for during their previous stay;
  6. If their break in skilled care lasts for at least 60 days in a row, this ends their current benefit period and renews their SKILLED NURSING FACILITY benefits. This means that the maximum coverage available would be up to 100 days of SKILLED NURSING FACILITY benefits; and
  7. They need these skilled services for a medical condition that was either:
    1. A hospital-related medical condition.
    2. A condition that started while they were getting care in the skilled nursing facility for a hospital-related medical condition.

Medicare Advantage has some coverage differences such as:

Some Medicare Advantage plans don’t require a three-day hospital stay. Some will provide coverage of at least the initial days at a nursing home even if the person is transferred right from her own home or has had less than the three day hospital stay.

It is also required by law that if a patient’s in-network physician orders tests or procedures that are not available or provided by any in-network facility or specialist’s office, the Medicare Advantage plan must pay for the patient’s procedures or services at an out-of-network location at no additional cost to the patient, so long as the necessary services are normally covered by Medicare.

Medicare Advantage plans typically do not contain deductibles while original Medicare has a potentially recurring (more than once a calendar year) deductible for Part A and an annual deductible for Part B.

Medicaid coverage of care is only available in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility.

Medicaid will cover nursing home care only when other payment options are unavailable and the individual is eligible for the Medicaid program.

If the patient still requires the care of a nursing home after the Medicare coverage has run out, the individual may pay privately, or use any long term care insurance they may have. If the individual exhausts all of their assets, is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid nursing facility benefit.

Dual Eligibles are beneficiaries such as low income elderly and disabled people, who are covered under both the Medicare and Medicaid programs. These beneficiaries are more likely than other Medicare beneficiaries to live with multiple chronic conditions and have functional and cognitive impairments. Medicare is their primary source of health insurance coverage, while Medicaid supplements, paying for services not covered by Medicare. Services such as long-term care services and support and by helping to cover Medicare’s premiums are advantages provided to dual eligible. Used together, these programs help to shield those with very low income from no access to healthcare and unaffordable care.

A breakdown of Medicare and Medicaid covered skilled nursing care specifics follow in the chart below. There are however, some time restrictions and federal interventions such as:

  1. Medicare’s Part A covers certain skilled nursing care services needed daily in a skilled nursing facility for a period of up to 100 days.
  2. A nursing facility participating in Medicaid must provide, or arrange for, nursing or related services and specialized rehabilitative services to attain or maintain the highest realistic physical, mental, and psychosocial wellbeing of each resident.

MEDICARE

MEDICAID

Semi-private room

(a room they share with other patients)

Room and bed maintenance services

Dietary counseling

Dietary counseling

Skilled nursing care

Nursing and related services

Medical social services

Medically-related social services

Medications

Pharmaceutical services

Speech-language pathology services

Emergency dental services (and routine dental services to the extent covered under the state plan)

Physical and occupational therapy

Specialized rehabilitative services (treatment and services required by residents with mental illness or intellectual disability, not provided or arranged for by the state)

Medical supplies and equipment used in the facility

Professionally directed program of activities to meet the interests and needs for wellbeing of each resident

Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the skilled nursing facility

Routine personal hygiene items and services

Meals

Meals

 

A discussion with your care providers may offer more information in special cases. For more information on Medicaid and Medicare you can visit www.medicaid.gov and www.medicare.gov.

 

About the Author

Amy comes to the OpenPlacement Blog with an extensive medical background, most recently, 16 years of medical experience as a serving member of the Canadian Forces.  Before enlisting in the military, Amy worked in both hospital and in-home care services spending countless hours with seniors in both palliative and non-palliative care settings. Upon releasing from the Canadian Forces she continues her passion for the medical field pursuing a career in medical and technical writing. Amy is currently completing an Advanced Diploma in Business Administration-Accounting and a graduate certificate in Technical Writing.

Email: barl0025@algonquinlive.com

Twitter: @barlow_amy

LinkedIn: www.linkedin.com/pub/amy-barlow/42/455/3a4

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