Medicare & Nursing Homes

Man with caregiver

Information in this section refers to original Medicare. If you have a Medicare Advantage Plan, you must check with your particular plan.

If you need help with understanding your health insurance, contact the Virginia Insurance Counseling & Assistance Program (VICAP) to find a counselor near you.

Click to Open or CloseOriginal Medicare Conditions to be Met

Original Medicare helps pay for nursing home care when the following are met :

  • The person needing care must have Medicare Part A (also referred to as Hospital Insurance);
  • There must be remaining days in the beneficiary's 'benefit period' or the beneficiary is eligible to begin a new benefit period;
  • The person needing care must have been an inpatientin the hospital for 3 or more days in a row. The count of days begins on the day the person is admitted into the hospital as an inpatient and ends the day before the person is discharged. The actual day that the person is discharged does not count as part of this 3 or more days hospital stay requirement.
  • The person must still be in need of reasonable and necessary skilled care for the medical condition for which they were treated in the hospital;
  • The person needing care enters a Medicare-certified skilled nursing facility immediately from the hospital or within 30 days of having been hospitalized;
  • A doctor must order skilled services for the person needing care. Skilled services are those specific services that need professional skills to be provided, such as the services requiring care by nurses or therapists; and
  • The skilled care services ordered by the doctor must be needed daily. (Note: if the person needing care is in a skilled nursing facility for rehabilitation services, care is considered daily even if only offered 5 or 6 days each week.)

Click to Open or CloseLimits to Medicare Part A Coverage of Skilled Care

Medicare Part A coverage of skilled care in a Medicare certified skilled nursing facility is limited to 100 days and only the first 20 days are covered in full by Medicare. Here is how it works:

  • For days 1-20: Medicare Part A pays the full cost and the person needing care pays nothing.
  • For days 21-100: Medicare Part A pays a certain amount and the person needing care is responsible for a daily co-payment unless they have a Medigap policy or Long Term Care Insurance that will pay this co-pay amount. (In 2014, this co-pay amount is $152 per day).
  • For days 100+: Medicare Part A pays nothing and the person needing care is responsible for the full cost out of pocket or through their supplemental insurance.

Click to Open or ClosePossible Problems & What You Need to Know

The 3-day qualifying hospital stay: Beware of Inpatient versus Outpatient

Medicare payment for skilled nursing facility care requires an inpatient hospitalization for 3 days immediately before admission to the nursing home. The person in the hospital must be classified or called an inpatient in the hospital for 3 or more days in a row. Sometimes hospitals and doctors admit a person under what is called 'Observation Services' which is officially considered by Medicare as an 'Outpatient' status even though the persons are being admitted to the hospital, in a hospital room receiving care and services longer than 24 to 48 hours. Often hospital patients are not aware of this problem. Understandably, they think if they have been admitted and are in a hospital bed in a hospital room and receiving care in the hospital that they are an inpatient.

The consequences of being hospitalized under Observation Services and called an Outpatient are as follows:

  1. Medicare Part A will not pay for the hospital stay;
  2. Medicare Part A will not pay for prescription medications received during the hospital stay; and
  3. Medicare Part A will not pay for care and/or rehabilitation in a Skilled Nursing Facility upon discharge from the hospital.

Ask the hospital if your stay is classified as Inpatient or Outpatient.

The nursing home may say Medicare will no longer pay for therapy because the resident is not improving

Sometimes a nursing home may say therapy must stop because Medicare will not pay for therapy since the resident has 'plateaued' or is no longer improving or making progress. However, sometimes therapy may be provided under Medicare even if the resident is not making progress, if it helps the resident maintain his or her level of functioning or slows the decline of the resident's condition.

A resident 'plateauing', or no longer making progress is NOT automatically a valid reason for denial of coverage by Medicare. Rehabilitation therapy for maintenance - maintaining one's current abilities - is a Medicare covered service. (Note: if a resident's condition makes therapy completely useless, meaning that therapy cannot help the person maintain their current health status and cannot prevent or delay decline, then therapy would not be prescribed and covered by Medicare.)

If you are told by the nursing home that therapy will stop due to the resident's 'plateauing' or lack of progress and Medicare will not pay, you can ask the nursing home to submit a bill to Medicare (this is known as a 'Demand Bill'). This will allow Medicare to make the decision about therapy rather than relying solely upon the nursing home's decision. (A word of caution is needed here in that if therapy is found not to be needed -- i.e. , if Medicare reviews and says 'no' to coverage -- the resident could be charged for the therapy services provided during the 'Demand Bill' process). Work with the doctor and the therapist to continue to provide therapy as appropriate and needed care.

Contact your Local Ombudsman for assistance.

Click to Open or CloseHelpful Information

  • Center for Medicare Advocacy, Inc. - CMA is a national non-profit group with a special focus on Medicare beneficiaries and their needs. Providing an array of information throughout the site, you may find the ‘Topic’ section particularly helpful.
  • Medicare Rights Center - The Center is a national, nonprofit service organization focused on access to quality care for elders and individuals with disabilities. They provide counseling, advocacy, and educational programs. If you have questions about Medicare, you may find their national Helpline helpful.
  • Medicare.gov - The Official U.S. Government Site for Medicare
  • For Complaints About Services Paid for by Medicare contact the Virginia Health Quality Center Consumer helpline at 1-800-545-3814.

Click to Open or CloseTerms to Know

  • Beneficiary is a term used for a person who has health care insurance through the Medicare program.
  • Benefit periods are certain periods of time that Medicare uses to track how many days of Medicare Part A services you have used. A benefit period begins on the day you have used the Medicare hospital or skilled nursing facility benefits and ends after 100 days of care. The benefit period is renewed when the person has not been in a hospital or skilled nursing facility for 60 days. Medicare beneficiaries are entitled to an unlimited number of benefit periods, but once one benefit period is finished, you have to again meet the criteria above, having another 3 or more day hospital stay after which you still require skilled care.
  • Custodial Care is care that does not need a professionally skilled staff person to perform. Custodial care consists of help with activities of daily living (bathing, dressing, eating, toileting, getting in and out of bed).
  • Skilled Care is care that needs a professionally trained person to perform, such as injections and physical therapy.
  • SNF is an abbreviation for 'skilled nursing facility' which is sometimes referred to or pronounced as 'Sniff'.