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Toby Laping Associates www.WNYCareManager.com
Eldercare News |
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Medicare and Long Term Care by Toby F. Laping, Ph.D., C.S.W. In spite of all of the publicity that Medicare has received in the last few years, many people are still unclear about what it covers, and they have unrealistic expectations about how much it will pay for a stay in a nursing home. It’s time to clear that up. Medicare will pay for care in a nursing home under certain very limited conditions and only for a limited period of time. IF a patient has been in a hospital for at least three days and was discharged from that hospital no more than a month before the nursing home admission (often the discharge is immediately from a hospital bed to a nursing home and that’s fine), and IF the patient has a skilled need that goes beyond what an aide is trained to do, and IF the patient is Medicare covered, and assuming the nursing home has a contract in place with Medicare, then Medicare will probably pay for the nursing home bed for a limited period of time. Even if all of the above conditions are met for a prolonged period of time, there is a 100 day limit to the number of days that Medicare will cover a patient each time he’s ill. When one enters a nursing home and is Medicare covered, that insurance will end as soon as the required conditions are no longer met. Many people are covered by Medicare for a few weeks and then they get a notification letter saying their coverage has ended. And, beginning with the 21st day, there is a co-payment that is approximately $100 per day. Often, secondary insurance will cover that co-payment but it’s important to confirm that. And, it’s common for secondary insurances to stop paying for a patient as soon as Medicare stops payment. As soon as any one of the required conditions for coverage as listed above no longer applies, Medicare typically stops paying for the nursing home. For example, if the patient has been in rehabilitation but it’s felt that he is no longer making sufficient progress to meet the Medicare standards, the patient or his family will be notified that Medicare coverage is about to stop and some other method of paying the nursing home must be identified. The letter notifying the patient or family that Medicare coverage is ending will also tell how to appeal that decision. If you believe that Medicare should continue to pay the nursing home, you should immediately follow the procedures and challenge the decision to stop Medicare coverage. Sometimes people wait in a hospital for a period of time before going to a nursing home, and they may be covered by Medicare under a category typically referred to as “Medicare skilled coverage”. That hospital wait as a “Medicare skilled patient” does not detract from the 100 days coverage in a nursing home for which people potentially are eligible. It’s reasonably safe to assume that certain conditions are likely to meet Medicare standards. For example, if an elderly person breaks a hip and goes to a hospital for surgery, and that patient then needs to go to a nursing home for short term rehabilitation, Medicare probably will pick up the cost for that short nursing home stay. On the other hand, if that hip is so badly shattered that the patient is not allowed to put any weight on it for a period of time, Medicare may not cover the patient’s costs while the patient is waiting for the time when she can again be weight bearing and can receive therapy. It’s also reasonably safe to assume that certain conditions are not likely to be covered by Medicare in a nursing home. For example, if an elderly patient has dementia but is otherwise quite healthy, and still he needs to be placed in an institution because his family is worn out and can no longer care for him safely, that patient probably will not be covered by Medicare for more than a very short time even if he has been in a hospital just before going to the nursing home. Even though the patient is in a “skilled nursing facility”, that doesn’t mean that the patient is getting the type of skilled care that qualifies for Medicare payment. There must be another means of paying the nursing home such as long term care insurance, paying out of pocket for a period of time, or Medicaid may be the payer in which event an application should have been made and ideally, already approved. The cost of nursing home care has been rising dramatically and it’s fairly common for nursing homes in Erie County to charge $225 daily. In light of that, it’s essential for people who see nursing home placement in their future to consider how they will pay those charges when Medicare doesn’t cover them. |