Nursing Home coverage through Medicare

Silver Tips is written by the Senior Citizens’ Law Office in Albuquerque.

Sometimes older adults are told that they need 24-hour care, or that they cannot live alone any longer. There are several options, including arranging more help at home, moving to an assisted living residence, or moving to a nursing home. Many people assume that if a Medicare beneficiary needs to move to a nursing home, Medicare will pay for it.

Medicare does pay for some nursing home stays, but it is very limited. It does not pay for long-term care. Medicare covers short-term nursing home stays for people recovering from acute illnesses such as a stroke or heart attack. Five conditions must be met in order for Medicare to pay:

1)    The patient must have Medicare Part A;

2)    The doctor must prescribe daily "skilled" care; that is, care that can only be provided by a licensed nurse or therapist;

3)    The nursing home must be certified by Medicare;

4)    The patient must have had a three-day inpatient hospital stay within the previous 30 days before entering the nursing home; and

5)    The patient needs skilled care for the condition that s/he was hospitalized for.

If a patient meets these criteria, Medicare can cover as much as 100 days of nursing home care during a "benefit period." Medicare pays everything for the first 20 days, but the patient is responsible for large co-payments ($105/day in 2003) for each covered day after the 20th. Medicare supplement insurance, also called Medigap insurance, may pay these co payments.

Medicare HMOs (available in the greater Albuquerque area and Santa Fe) are required to provide at least the same coverage as original Medicare, and they may not require a prior hospitalization or daily co-payments.

Specific criteria define what skilled-level care is, and each patient's individual needs and abilities must be considered. Unfortunately, skilled care is often interpreted too narrowly, especially by HMOs. Patients can, however, appeal if services are denied or stopped too soon.

Original Medicare patients can appeal to the Medicare claims processing company for Part A. Medicare HMO members can appeal to their HMO and later to an independent review agency called the Center for Health Dispute Resolution (CHDR).

Whether the nursing home or the HMO makes the coverage decision, patients have the right to a written notice that explains their appeal rights. Often a patient's nursing home stay will begin at the skilled level of care, but the nursing home or HMO will later decide that they no longer qualify for skilled coverage. Written notices are required at that time as well, and the same appeal rights apply.

Original Medicare patients face an additional hurdle. If a nursing home thinks that a patient does not meet the requirements for skilled care, it might not submit a claim to Medicare. The patient, however, can ask the nursing home to submit a claim anyway (called a "demand billing") in order to get a Medicare coverage ruling, which can then be appealed. The nursing home cannot bill the patient for a continued stay until Medicare decides the claim.

Many other details about skilled nursing home care have not been described here. Medicare publishes a helpful guide called "Medicare Coverage of Skilled Nursing Facility Care" and anyone can get a free copy by calling the New Mexico Aging and Long-Term Service Department's Health Insurance and Benefits Assistance Corps (HIBAC) toll-free statewide number at 1-800-432-2080; residents of Bernalillo County can call HIBAC at 265-1244.