Ask the Expert- Is Medicare Enough to Cover Mom’s Nursing Home Stay?

Q. My 86 year old mother had a stroke last week, was in the hospital,  and was moved to a nursing home for rehabilitation.  I was wondering about Medicare coverage. Does Medicare cover nursing home stays? What if she needs more than the 100 days I read about?

   A. Many people believe that Medicare covers nursing home stays. It is true that Medicare covers up to 100 days of short-term rehabilitation per illness, but  there are a number of requirements that must be met before this short-term rehab stay will be covered. The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.

In order for a nursing home stay to be covered by Medicare:

  • The patient must enter a Medicare-approved “skilled nursing facility” or nursing home within 30 days after a hospital stay that lasted at least three days.
  • The short-term rehabilitation care received in the nursing home must be for the same condition as the hospital stay. In addition, you must need “skilled care.” This means a physician must order the treatment and the treatment must be provided daily by a registered nurse, physical therapist, or licensed practical nurse.
  • Finally, Medicare only covers “acute” care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing.

It is important to understand that Medicare does not pay one penny for long-term care. (This section is excerpted from Evan H. Farr, CELA’s book “Nursing Home Survival Guide- Helping You Protect Your Loved Ones Who Need Nursing Home Care by Preserving Dignity, Quality of Life, anFinancial Security,” available on Amazon.com)

“If you are enrolled in a traditional Medicare plan, and you’ve been in the hospital at least three days, and you are admitted directly from the  hospital into a rehab facility (which are typically skilled nursing facilities for short-term rehabilitation (i.e., therapy and treatment designed to make you better), then Medicare should pay the full cost of this short-term rehab stay for the first 20 days, and may continue to pay part of the cost of the short-term rehab stay for the next 80 days — with a per day deductible that you must pay privately (although there are Medicare supplement insurance policies that sometimes cover that deductible). There is also a Medicare Managed Care Plan, for which the 3-day hospital stay may not be required, and for which the deductible for days 21 through 100 is waived, provided certain strict qualifying rules are met But whether the plan is traditional Medicare or Medicare Managed Care (MMC), the nursing home resident must be receiving daily rehabilitative care and must be improving. Medicare does not pay for long-term care  i.e., for custodial nursing home stays or in-home care. In a best case scenario, traditional Medicare or MMC will provide some coverage for the hospital stay and rehabilitation of up to 100 days for each “spell of illness” (although in our experience coverage usually falls far short of the 100-day maximum). If you recover sufficiently that you do not require a Medicare-covered care benefit for 60 consecutive days, you  may be eligible for another benefit period, i.e., another 100 days of Medicare coverage, but the illness or disorder must not be a chronic degenerative condition from which you will not recover. What happens if you’ve used up the 100 days of coverage and still need  more rehabilitation, or if you need to move into long-term nursing home care? You’re back to one of the alternatives outlined above: long-term care insurance, paying the bills with your own assets, or qualifying for Medicaid.”

Did you know that nursing homes in Northern Virginia cost 10-12K a month? For typical middle-class people who pay out of pocket, these costs will most likely drain all of their hard-earned assets pretty quickly. For more information, read our recent blog post “How Can I Afford a Nursing Home?”.

Do you have a loved one who is in a nursing home or nearing the need for nursing home care? Or are you simply looking to plan ahead in the event nursing home care is needed in the future?  Life Care Planning and Medicaid Asset Protection is the process of protecting your assets fro  having to be spent down in connection with entry into a nursing home, while also helping ensure that you or your loved one get the best possible care and maintain the highest possible quality of life, whether at home, in an assisted living facility, or in a nursing home. Learn more at The Fairfax and Fredericksburg Elder Law Firms of Evan H. Farr, P.C. website. Call 703-691-1888 to make an appointment for a no-cost consultation.

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