Medicare Guide for Nursing Homes

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Medicare covers limited nursing home care and services provided by skilled nurses, technicians, or therapists. For Medicare coverage in a nursing home, you must have a three-day qualifying stay in the hospital, although some Medicare Advantage Plans may waive this requirement. Nursing homes, also called skilled nursing facilities (SNFs), provide short and long-term care. Long-term care is typically for people who need 24-hour supervision and nonskilled, custodial care, which Medicare does not cover.

Nursing home room and board rates vary from state to state and are an expensive alternative to other levels of care at home or in an independent or assisted living facility. Medicaid is the primary payer for nursing home care for people with low income and resources. Finding ways to pay for nursing home care is a challenge and may require the assistance of insurance agents, financial planners, and social services or Medicaid resources in your area.

Moving yourself or a loved one to a nursing home is a tough decision. Sometimes, it’s the best way to keep someone safe, especially if their health or mental status has deteriorated. Nursing homes must ensure that residents’ rights to privacy, respect, self-determination, and more are upheld. Any violation of rights must be investigated and may involve the nursing home’s ombudsman, who serves as an advocate for all residents.

What Is a Nursing Home?

A nursing home is a facility where people reside on a short or long-term basis to receive skilled or custodial around-the-clock care. Nursing homes must be licensed to operate in their state. Nursing homes must also be certified by the Centers for Medicare and Medicaid Services (CMS). State surveyors ensure that nursing homes meet licensure and certification requirements.

Most nursing homes serve as SNFs for people recovering from an illness or injury and long-term care facilities for people who can’t live at home.

What Is the Difference Between a Nursing Home and Assisted Living?

Assisted living facilities (ALFs) are homes for people who need help with their care and activities of daily living but not to the level or extent a nursing home provides. Typically, ALFs are regulated and licensed by the state in which they operate.

There are different “levels of care” in most ALFs catering to the needs of individual residents. Lower levels of care are for more independent people while higher levels provide more assistance. Costs rise with the level of care. If someone’s needs exceed what the ALF can provide, staff may recommend transfer to a nursing home.

Medicare will cover some of the costs for skilled care in a nursing home but typically will not cover assisted living facility care.

What Are Your Nursing Home Care Rights Under Medicare?

According to the CMS, you have rights and protections under federal and state law as a nursing home resident, including the right to:

  • Be informed
  • Make your own decisions
  • Have your personal information kept private
  • Receive information about your rights and responsibilities in writing in a language you understand ― before you are admitted
  • Be treated with dignity and respect, free to make your own daily schedule
  • Participate in activities offered at the facility
  • Be free from discrimination based on race, color, national origin, disability, age, or religion
  • Be free from verbal, physical, sexual, and mental abuse and neglect
  • Report abuse and neglect ― the nursing home must investigate any reports within five working days to proper authorities
  • Be free from chemical (drugs) or physical (like side rails) restraints put in place for the staff’s convenience
  • Make complaints without fear of punishment
  • Get proper medical care, being fully informed and involved in your plan of care
  • Have your representative informed if your condition or treatment needs change or the nursing home plans to transfer or discharge you
  • Get written information on services and fees when you are admitted and if services and fees change
  • Manage your own money or have someone you trust do this for you; if you ask the nursing home (in writing) to keep an account for you, they must protect your funds
  • Get proper privacy, property, and living arrangements, including sharing a room with your spouse if you both agree to do so
  • Spend private time with visitors
  • Get social services to help with counseling, social, legal, and financial problems and discharge planning
  • Leave the nursing home for visits or to move out
  • Have protection against unfair transfer or discharge
  • Form or participate in resident groups or councils
  • Have your family and friends involved with your care

All states must have a long-term care (LTC) Ombudsman program. A nursing home ombudsman serves as an advocate for residents helping to resolve problems or violations of rights. Residents and family members can ask nursing home administrative staff about how to contact their local ombudsman.

What Parts of Medicare Cover Nursing Home Care?

Medicare Type What Nursing Home Care It Covers
Medicare Part A Medically necessary skilled care in a Medicare-certified SNF on a limited basis ― up to 100 days per benefit period ― after a qualifying hospital stay.
Medicare Part B Physician services, medical equipment, and supplies for a non-Part A covered stay. Certain outpatient prescription drugs
Medicare Advantage (Part C) Follow the same coverage guidelines as Original Medicare Parts A and B, but you may not need a qualifying hospital stay. Most plans require you to receive services from a network facility.
Medigap (Medicare Supplement Insurance) 100% SNF coinsurance for Part A-covered stay with Plans C, D, F, G, M, N. Plan K pays 50%, Plan L pays 75%. There are no benefits for custodial nursing home care.
Medicare Part D Prescription medications from a long-term care pharmacy that works with your plan.

Who Is Eligible for Medicare Coverage of Skilled Nursing Care in a Nursing Home?

Medicare only covers skilled nursing care in specific circumstances. This holds true whether you get your Medicare benefits through Original Medicare or a Medicare Advantage Plan. As a Medicare beneficiary enrolled in Medicare Part A, you are eligible for coverage of skilled nursing care in a nursing home if the following conditions are met:

  • You have days left in a benefit period to use. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t gotten any inpatient hospital care or skilled care in an SNF for 60 days in a row.
  • You have a qualifying hospital stay of at least three days, you enter the SNF within 30 days, and need skilled care. Medicare Advantage Plans may waive this requirement, but you may need prior authorization from your plan.
  • Your skilled care is provided in a Medicare-certified SNF.
  • Your doctor says you need daily skilled care provided by, or under the supervision of, skilled nursing or therapy staff.
  • Your need for skilled services is related to one of the following:
    • a medical condition treated during your qualifying inpatient hospital stay
    • a condition that started while you were getting care in the SNF (for instance, if you develop an infection or complication that requires skilled care like IV antibiotics)

What Are Nursing Home Services?

Nursing home services encompass a wide range of health and medical services and assistance with activities of daily living like eating, bathing, and getting dressed. Nursing homes provide 24-hour supervision from paid staff who serve as primary caregivers. The majority of nursing home services are custodial in nature, but Medicare-certified nursing homes also can provide the highest level of skilled care available outside of the inpatient hospital setting.

What Nursing Home Services Does Medicare Cover?

Medicare-covered nursing home services must be provided by, or under the supervision of, skilled professionals or technical staff. Nursing home personnel manage your care, evaluate your progress, and document the results of your treatment. Nursing home services must be ordered by your physician. Covered services include:

  • Semi-private room, which is a room you share with other patients
  • Meals
  • Skilled nursing care
  • Physical therapy, if needed to meet your health goal
  • Occupational therapy, if needed to meet your health goal
  • Speech-language pathology services, if needed to meet your health goal
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation ― when other transportation endangers your health ― to the nearest supplier of needed services that aren’t available at the SNF
  • Dietary counseling
  • Swing bed services ― you may receive care in certain hospitals that can provide either acute hospital or SNF-level care, and your costs and coverage apply as though you received services in an SNF

What Nursing Home Services Does Medicare Not Cover?

Medicare does not cover:

  • Custodial care, if it’s the only care you need
  • Long-term care
  • Room and board
  • Services that are not deemed medically necessary or are not on your physician-ordered plan of care
  • A private room, unless your doctor says it is necessary for your condition
  • Ambulance transportation if you can safely be transported another way
  • Care provided at a facility that is not Medicare-certified

When Should You Consider Nursing Home Care for Yourself or a Loved One?

Nursing home care for a short time to help you or a loved one recover from an illness or injury may be necessary until independence can be regained. Nursing home care for the long term may be required when you can no longer safely care for yourself or a loved one. However, it’s a big step and an expensive one, too. There are many potential stops along the way, with nursing home placement as a last resort.

There are important factors that weigh into the decision to seek admission to a nursing home for yourself or your loved one:

  • What you or your loved one wants: For most people, moving into a nursing home signals the end of their independence. Autonomy, the right to choose and speak for themselves, is an important ethical concept that should not be discounted. Everyone should always be respected and educated about their options. Even if a nursing home ends up being the only safe choice, they have a right to be part of the decision-making process. Being involved and informed allows people some control and self-determination.
  • Safety: One of the main reasons people live in nursing homes is because they cannot be safely managed in the home or community and require 24-hour supervision. Independent living or assisted living facilities do not provide around-the-clock services. Sometimes, elderly spouses cannot safely take care of their loved ones at home.
  • Availability and willingness of caregivers: A caregiving system, which can consist of family, friends, neighbors, and hired help, is essential for people who cannot safely take care of themselves. The potential for caregiver burnout is high and is a frequent driver for nursing home placement.
  • Cost: Nursing home care is the most expensive option. Independent or assisted living facilities can be expensive but are less than a nursing home. If you or your loved one doesn’t require 24/7 services but still need some assistance, a facility with some supervision or a board and care home are intermediate steps. Some people manage to stay in their own homes with live-in or intermittent hired nonskilled caregivers. This option can be expensive as well. Hired staff turnover and finding the right fit for you or your loved one can also be problematic.

If you have access to social workers in your community, take advantage of the counseling and resources they have to offer. If you are considering nursing home placement for yourself or a loved one, there is probably a physical or mental health issue at play. You may be a good candidate for palliative care services and would have access to a medical social worker (MSW). Your physician or local Area Agency on Aging may refer you to a social worker or long-term care representative who can help you sort out the options available to you.

What Is the Difference Between Short-Term and Long-Term Nursing Home Care?

Short-term nursing home care

Short-term nursing home care, as the name implies, is for a limited amount of time. This type of care typically is Medicare-covered skilled care that is rehabilitative and restorative after an illness or injury. The goal is to improve your health status so you can return to your previous level of functioning.

Long-term nursing home care

Long-term nursing home care is for an extended period of time and is typically custodial in nature. Medicare does not cover this type of care. The goal is to maintain your health status and safety.

How Much Does a Nursing Home Cost?

Nursing home costs can vary depending on these factors:

  • Location: Costs are different in each state, ranging from $180/day in some southern states to over $1,000/day in parts of Alaska. The nationwide average daily cost of a shared room is $260/day.
  • Private or shared room: Private rooms are more expensive and are not subsidized by Medicaid. Medicare will not pay for a private room even if you qualify for Medicare skilled care.
  • Services required: Some nursing home rates are all-inclusive and some charge additional fees for things like physical or speech therapy or memory care.
  • Low-come subsidy vs. private pay: If you pay privately, your daily rate is higher than what Medicaid pays. If you meet Medicaid income and resource limits, Medicaid will pay the nursing home. Limits vary by state, but on average your assets must be valued at less than $2,000 and your monthly income must be less than $2,523 (in 2022).
  • Medicare-covered: If you are eligible for skilled care after a qualifying hospital stay, Medicare will pay 100% of nursing home costs for the first 20 days and 80% for days 21 – 100. Medicare will not cover any costs after that.

What Are Your Options to Help Pay for Nursing Home Care?

Nursing home billing and administrative staff work with families to set up payment for their loved one’s care. Along with the nursing home’s social worker, they are your front-line experts for exploring payment options. It is mutually beneficial for them to help you find resources. Here are some options to consider.

Medicaid

Medicaid is a joint federal and state program that covers most healthcare costs if you qualify. Most nursing homes accept Medicaid, which is the primary payer for long-term care. Medicaid eligibility varies by state. Contact your state Medicaid office to get more information. You may be eligible for Medicaid coverage in a nursing home even if you haven’t qualified for Medicaid before.

Long-term care insurance

Long-term care insurance is a type of insurance policy that helps pay for nursing home care, including skilled and nonskilled care. Benefits vary depending on how comprehensive your policy is. If you don’t already have a policy in place, it may be difficult to find one that is affordable based on health status and preexisting conditions.

Assets

Use your personal resources, savings, annuities, or retirement accounts to free up funds. It’s best to talk with your financial or tax planner about the best way to do this. Some people “spend down” their assets until they are eligible for Medicaid. There are rules about how you can legally spend down financial resources. These rules vary by state. Consider contacting a Medicaid planner through the MedicaidPlanningAssistance.org to help determine your eligibility requirements. MedicaidPlanningAssistance.org is a free service provided by the American Council on Aging.

Whole life insurance

You may be able to draw cash from a whole life insurance policy. Talk with your policy representative about your options and tax consequences.

Veteran benefits

Veterans may receive long-term care benefits through the United States Department of Veterans Affairs (VA). Veterans with service-related injuries or disabilities can get help paying for nursing home care at specific locations. To find out your level of benefits and how to access them, contact your VA social worker. Alternatively, call the VA’s toll-free hotline at (877) 222-8387, Monday through Friday, 8 a.m. to 8 p.m. Eastern time.

Loans

Take out a bridge loan, a home equity loan, or a reverse mortgage. Talk with your bank or mortgage company about which option would be best for you and your financial situation.

Income

Create another source of income, such as renting out a room.

Medicare for Nursing Homes Expert Tips
  • If you are considering a nursing home for long-term care, plan ahead if you can. Have conversations about the possibility of a nursing home down the road. Talk early, talk often. Involve your loved one in decision-making if at all possible.
  • Visit the nursing home you are considering. Plan to spend a few hours there and talk with as many residents and family members as you can about their experience. Notice the atmosphere and how the nursing home smells. Interview the administrator and ask about how they handle complaints and how they involve the residents and family in the plan of care. Spend time in the dining room as well.
  • Try to find a quality nursing home as close to your home as possible to make frequent visits more feasible. However, choose quality over proximity.
  • Understand Medicare’s rules about coverage of skilled care if you are going to a nursing home for a short-term stay after hospitalization. Talk with the hospital discharge planner and the nursing home admissions nurse or social worker. If you have a Medicare Advantage Plan, make sure you have prior authorization for a network facility.

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    As a health care professional since 1987, Kelly Blackwell has walked alongside and cared for seniors as they journey through the season of their fourth quarter of life. Blackwell holds a Bachelor of Science in nursing from the University of Northern Colorado, a Master of Science in health care administration from Grand Canyon University, an interprofessional graduate certificate in palliative care from the University of Colorado Anschutz Medical Campus and holds a Certified Senior Advisor® credential from the Society of Certified Senior Advisors.

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