Medicare Your Coverage Options

Medicare coverage of nursing home care is very limited

Written by Diane Archer

Planning ahead for a time when you may not be able to care for yourself means recognizing that, unless you qualify for Medicaid, you may need to pay out of pocket for nursing home care. Medicare coverage of nursing home care is very limited.

Unlike Medicaid, Medicare never pays for custodial nursing home care, basic care that does not require treatment from a skilled nurse or therapist. Medicare only covers nursing home care for people needing skilled care who have been hospitalized as an inpatient for at least three days in the 30 days prior to admission in a nursing home. If you meet these criteria, Medicare should cover your care for up to 100 days (the first 20 days in full and the remaining 80 days with coinsurance) 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 physical therapy services at least five or six days a week; and your doctor certifies your need for this care.

Note: Medicare should pay for nursing home care that helps maintain your condition as well as care that improves your condition.

On admission, it is possible that a Medicare-certified 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. The nursing home may do so to protect itself financially if Medicare denies coverage because Medicare does not think you meet the coverage criteria.

If you sign the waiver, you may be financially liable if Medicare does not cover your care.  However, you should make sure that the nursing home still submits the claim to Medicare, along with a letter from your doctor explaining your need for daily skilled services. This is called a “demand bill.” There is a good chance that Medicare may ultimately pay for your care.

If the nursing facility admits you without asking you to sign the waiver, you are not financially liable if Medicare denies coverage. But, if the nursing home asks you to sign the waiver prior to admission and you refuse, the nursing home is not obligated to admit you.

Keep in mind that hospitals sometimes admit people as outpatients on observational status and not as inpatients.  Even if you stay overnight for three days and you are admitted as an outpatient, you will not qualify for skilled nursing facility care, regardless of whether you need it. Speak to your doctor about ensuring you are admitted as an inpatient if you are hospitalized.

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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