Will Medicare cover my stay in a Skilled Nursing Facility? Medicare will cover skilled care if the following is true:

• You have Medicare Part A (Hospital Insurance) and have days left in your benefit period.
• You have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. You must enter the Skilled Nursing Facility (SNF) within 30 days of leaving the hospital.
• You require skilled care on a daily basis. Skilled care is health care given when you need skilled nursing or rehabilitation staff to treat, manage, observe, and evaluate your care. Examples of skilled care include physical, occupational and speech therapy at least 5 days per week; wound care; IV antibiotic therapy; etc.

If I meet the above criteria, what type of coverage am I eligible for?

If you meet the above criteria and are admitted to a skilled nursing facility, you may be eligible for up to 100 days of coverage available under the Medicare program. The Medicare program will pay the full cost of your first 20 days in a skilled nursing facility. The next 80 days (days 21-100) you will be responsible for a daily rate of $144.50/day for the nursing care with Medicare making up the difference. This rate usually increases each year on January 1. If you have a supplemental insurance plan and it has Skilled Nursing benefits, it will cover the daily co-insurance.

What is a Benefit Period?

Medicare uses a period of time called a benefit period to keep track of how many days of SNF benefits you use and how many are still available. A benefit period begins on the day you start using hospital or SNF benefits under Part A of Medicare. Once you use those 100 days, your current benefit period must end before you renew your SNF benefits.

Your benefit period ends:

• when you have not been in a SNF or a hospital for at least 60 days in a row, OR
• if you remain in a SNF, when you haven’t received skilled care there for at least 60 days in a row.

There is no limit to the number of benefit periods you can have. However, once a benefit period ends, you must have another 3-day qualifying hospital stay and meet the Medicare requirements before you can get up to another 100 days of SNF benefits. If you require re-admission to a skilled nursing facility prior to the start of a new benefit period, your Medicare SNF benefit period will continue where you left off last time you left a SNF. Example: You received 10 days of Medicare-covered SNF care for a broken leg and discharged home. After 10 days, your doctor decided you needed more skilled care for your broken leg and readmitted you to the SNF. Medicare will cover this SNF stay starting on day 11. You will have 90 days of coverage left in your benefit period.

Medicaid

Eligibility is determined by resources, income and medical necessity. Medicaid assists eligible patients with the monthly cost in a nursing home for both skilled and intermediate care. The patient’s monthly income minus $40 per month for personal use, is applied to the monthly cost of the nursing facility. Medicaid adds to the amount the patient has as income, to reach the total amount required by the nursing home.

What resources can I have and still be eligible for Medicaid?

The resources of a person applying for Medicaid as well as their spouse are considered. The spouse who remains at home or the community spouse may keep a minimum monthly case allowance of $1,823. Depending on allowable expenses this amount can increase to a maximum of $2739 per month. The maximum cash resources for the community spouse cannot exceed $109,560.

How does Medicaid define resources?

Resources are defined as cash money and any other personal or real property that person or couple owns. Resources may include, but are not limited to: checking accounts, stocks and bonds, certificates of deposit, automobiles, land, burial reserves, life insurance policies, and savings accounts. There are five types of financial coverage for nursing home costs: Medicare, Medicaid, Private Insurance, Personal Funds and Long Term

What resources are exempt and not considered in the Medicaid eligibility determination?

• $1,500 – $2,000 (for use by the nursing home resident)
• The home, if the applicant has been in a nursing home less than six months or if the home is occupied by a spouse, dependent or disabled child, or a sibling with an equity interest who has living in it for at least a year.
• One vehicle, regardless of value
• The cash surrender value of the nursing home resident’s life insurance policies if the face value of all policies total $2000 or less.
• An irrevocable pre-burial contract and burial plot
• A trust established by will or someone other than the nursing home resident or spouse
• Any resource not available to the nursing home resident

Private insurance

Some insurance plans may cover all or a portion of skilled nursing facility costs. It is important to know if the skilled nursing facility is a participating provider with your insurance company. Your policy will indicate the extent of your coverage, or you may wish to call your insurance agent or company benefits manager to discuss details. The Executive Director can assist with checking your skilled nursing benefits and determining what out of pocket expenses are your responsibility.

Will the skilled nursing facility bill me or the insurance company?

Yes, the community will bill your private insurance company directly. You will be responsible for payments not received by your insurance carrier.

Personal funds/private pay

If you do not qualify for Medicare/Medicaid benefits, you may enter a skilled nursing facility on a private pay basis. If you intend to pay privately for skilled nursing care, please notify the Executive Director who will assist you with arrangements.

Long term care insurance

Long term care insurance can be purchased to cover the cost of a nursing home and occasionally home health care not covered by the Medicare program. Policies are sold individually as well as through employers. Policies may vary by restrictions, type of care, method of payment and length of coverage, making them difficult to compare.