Medicare pays for nursing home sometimes
Apr
7
Written by:
4/7/2008 4:00 AM
By Betty Berry
Monday, April 7, 2008
Q. I am confused about what Medicare will pay for when someone is in a nursing home. I've heard of cases where Medicare has paid nothing and others where Medicare pays for everything. Why would there be such a range of benefits?
A. First, I am assuming that when you mention a nursing home, you are referring to a skilled nursing facility, also known as an SNF, and my response to your question will be based on that assumption.
The difference depends on why you are in an SNF. If you are there because you need custodial care, then Medicare will not cover the cost of your stay. However, if you are there because your situation requires skilled care or therapy, then Medicare will fully cover part of your stay.
If you are in an SNF because of the need for custodial care, it means that you need help with daily living activities known as ADLs, including bathing, dressing, eating, using the bathroom and transferring — getting from a bed to chair or chair to bed-type needs.
It could also include the type of care people usually do for themselves such as administering eye drops, oxygen, etc.
Custodial care is often provided in an SNF, but is not covered under Medicare benefits. If someone has a long-term care policy, it would cover costs as would private pay. Medi-Cal is the government program that could provide financial assistance if the patient meets Medi-Cal's qualifications.
Skilled care requires the involvement of skilled nursing or rehabilitative care and can include the services of registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists and audiologists.
Medicare will cover skilled care when you meet certain conditions and on a short-term basis not to exceed 100 days.
You must be enrolled in Medicare Part A (hospital insurance coverage), and you must have a qualifying hospital stay. A qualifying hospital stay means that you were a patient at an acute care hospital for three consecutive days or more, not including the day you are discharged, and you must enter the SNF within 30 days of leaving the hospital.
In addition, your doctor must prescribe that you need daily skilled care and it must be under the direct supervision of nursing or rehabilitation staff. These services must be provided at a Medicare-certified SNF.
If you meet all of these qualifications, Medicare benefits will cover skilled care or therapy in an SNF at full cost for the first 20 days and partially for the following 80 days. The partial co-insurance for days 21-100 by the patient is $128 per day. However, the coverage can be stopped during that 100-day period if skilled care or therapy is no longer required. Beyond 100 days, there is no coverage by Medicare.
I hope that this helps to explain the difference between the two examples that you mentioned.
Q. My neighbor just told me that she has been attending seminars at the Westlake Village Civic Center that address issues of interest to seniors. Can you tell me about these seminars?
A. Your neighbor is right on the mark. Senior Concerns in cooperation with the city of Westlake Village present a monthly seminar at the Westlake Village Civic Center complex.
The series is known as "Senior Issues" and is scheduled the second Wednesday of every month from 1:30 to 3 p.m.
The next presentation is scheduled for Wednesday and will talk about "Whose Responsibility Is It? If Not Yours, Then Whose?"
This seminar looks at the various programs, opportunities and situations that each of us face on a daily, weekly, monthly or yearly basis. Do we understand the rules and regulations associated with those programs? Are we aware of the opportunities available to us? Do we investigate the options we have in different situations?
If we don't take responsibility for understanding, being aware and investigating things that may be beneficial to us, then who does?
Why not plan to attend and see what you can learn as well as what you can offer to the group.
For information about the series or this seminar, call the advocates office at 495-6250.