More than 800,00 adults in the United States reside in some type of assisted living community. There are more than 30,000 such communities throughout the country, offering various levels of care and distinct services, including skilled nursing home health care.
HOne of the most common questions for people who are moving into an assisted living home is what if Medicare covers costs? This is a difficult question to answer, as it relates to particular types of services enrollees receive.
This article covers what those are. Keep reading to find out where Medicare coverage areas and boundaries lie, so you can determine how it relates to your circumstances.
What Does Medicare Cover?
Medicare is a federal health insurance program for Americans 65 years of age or older, as well as certain younger people with disabilities or ailments (like end-stage renal disease). It was first proposed in the 1940s but was not signed into law in 1965. Today, it covers more than 67 million people.
Medicare covers a broad range of medical services. These include everything from hospital care and doctor visits. Coverage can also extend to home health care and related medical equipment.
Medicare has different many different parts and configurations. These include:
- Medicare Part A
- Medicare Part B
- Medicare Part C
- Medicare Part D
- Medigap
Which plan an individual has determines what services the program will pay for.
Medicare Part A
Medicare Part A is insurance for hospital services. This includes inpatient hospital stays and could cover some skilled nursing care (more on that below). It also can extend to some home health care services, such as hospice care.
Medicare Part A is not optional, meaning if you enroll in Medicare you receive Part A. It does not require any premiums.
Medicare Part B
Medicare Part B is the part of the program that provides medical insurance. This includes doctor visits, including specialists.
Medicare Part B also covers various outpatient hospital services, including preventive services. Examples include screenings for disease and vaccinations. In some situations, Medicare Part B can cover some home health care and medical equipment, like wheelchairs or oxygen tanks.
Medicare Part B is optional, so Medicare enrollees have to choose whether they want it when they enroll. It does require monthly premiums for enrollees.
Medicare Part C
Medicare Part C is often referred to as “Medicare Advantage.” It is a group of health insurance plans offered by private companies that must be approved by Medicare. Like most other private insurance plans, there are in- and out-of-network providers.
Medicare Part C plans also have a drug coverage component to them. Some plans can include other benefits, like vision, dental, and hearing services.
Medicare Part C is optional. However, one criterion is that, if someone wishes to sign up for a Medicare Advantage plan, they must be signed up for Medicare Part A & B.
Medicare Part D
Medicare Part D is the prescription drug coverage component of Medicare. Like Medicare Part C, Part D is offered through private insurance companies approved by Medicare. To get Medicare Part D, people must be enrolled in Medicare Part A and Part B.
Medigap
Medigap is a supplemental insurance plan sold by private companies. It is often differentiated from the other components of “traditional Medicare.”
That is because it is not purchased through the Medicare program but, as the name suggests, as a policy to fill in the gaps in traditional Medicare plans. Common examples include out-of-pocket costs, including deductibles, copayments, and coinsurance. It could also cover specialty services not offered by traditional Medicare.
Does Medicare Cover Skilled Nursing Home Care?
To understand whether Medicare covers skilled nursing home care, it may first be helpful to look at what it does not cover.
In general, it does not cover custodial care. This refers to non-medical activities of daily living, such as bathing, dressing, and eating.
Keep in mind that this is the case if custodial care is the only type of services you require. However, some of these services, such as medication management, could be covered, if it is part of another treatment regimen that is covered.”
What Skilled Nursing Services Does Medicare Cover?
As mentioned, Medicare Part A covers qualifying inpatient hospital stays. Fortunately, skilled nursing home care falls within this category. There are a few criteria though.
- “Qualifying” hospital stay
- Necessity of skilled nursing care
- Other criteria
The first criterion for gaining Medicare coverage for skilled nursing home care is that it follows a “qualifying” inpatient hospital stay. This relates to the duration of hospitalization.
In general, it requires that you spend at least three days in the hospital. (Medicare counts the first day but not the day of discharge.)
Next, you the patient must require skilled nursing or therapy services that can only be provided by skilled nursing care. For instance, if there are options for receiving therapy at another center, then Medicare may not cover it.
Finally, the skilled nursing community must be Medicare-certified for coverage to kick in. Also, the care being received must be directly related to the condition that required hospitalization.
Coverage Details
Next, there are some skilled nursing care coverage constraints. First, it will cover the following services:
- Medical-related skilled nursing care services
- Medications
- Medical supplies and equipment
- Meals
- Semi-private room
- Physical, occupational, and speech-language therapies
In general, you can expect Medicare to cover 100 percent of medical costs for the first 20 days. Medicare will also pay for services between 21 and 100 days. However, there is a $200 per day coinsurance fee.
Medicare does not cover long-term care. For this reason, coverage will cease after 100 days.
Find Skilled Nursing Home Health Care Near You
Now that you understand the basics of Medicare coverage for skilled nursing home health care, you can determine how it applies to your circumstances.
Discovery At Home provides the highest level of skilled nursing care to its residents throughout Florida and Texas. We pride ourselves on professional, compassionate staff and comprehensive programming and services for residents. Reach out to us today to schedule a free tour or to discuss nursing home benefits.
