Medicare Your Coverage Options

Medicare coverage of nursing home care is very limited

Written by Diane Archer

Anyone thinking that Medicare will pay for their nursing home care if they need it should think again.  Medicare coverage of nursing home care is very limited. Unlike Medicaid, Medicare never pays for custodial care in a nursing home, basic care that does not require treatment from a skilled nurse or therapist.  And, unless you have been hospitalized for at least three days as an inpatient in the 30 days prior to admission in a nursing home, Medicare also will never cover your nursing home care.  If you meet these criteria, Medicare should cover your care for up to 100 days if:

  1. You are admitted to a Medicare-certified skilled nursing facility; and,
  2. You need daily skilled nursing services, seven days a week or you need physical therapy services at least five or six days a week. Your doctor must certify your need for this care. Medicare should pay for care that helps maintain your condition as well as care that improves your condition.

To protect itself financially, the nursing home may tell you that it does not believe Medicare will cover your care and ask you to sign a waiver agreeing to pay for the care you will receive. If you sign that waiver you will be financially liable if Medicare does not cover your care.  You will also need to direct the nursing home to send your claim for coverage to Medicare for a determination.

Keep in mind that hospitals may not admit you as an inpatient but rather as an outpatient on observational status.  Even if you stay overnight for three days, you will not qualify for skilled nursing facility care, regardless of whether you need it.

Click here to learn about your rights in a nursing home. And, don’t be misled by five-star nursing home ratings.

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