How does Medicare cover Skilled Nursing?
Long Term Care? * Home Health Care?
Skilled nursing facility care
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services
(Clinical Guidelines – Oscar – Explains Medical Necessity Requirements so much better and in logical order!)
and supplies furnished in a skilled nursing facility after a 3-day minimum, medically necessary, inpatient hospital stay Medicare Policy Manual * Publication 10153 SNF * for a related illness or injury. An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to help improve or maintain your current condition.
A SNF is a care center where nurses and nursing assistants are available to provide twenty-four hour care for patients to assist them with conditions in their transition between the hospital and a lower level of care such as the home. A SNF may also provide rehabilitation in order to improve the member’s function and decrease the burden of care. Oscar Clinical Bulletin *
To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous injections or physical therapy) which, as a practical matter, can only be provided in a skilled nursing facility if you’re an inpatient.
You pay:
- Nothing for the first 20 days of each benefit period
- $185 Coinsurance per day for days 21–100 of each benefit period
- Sample Medicare Advantage Copay
- Medicare Advantage must pay at least as well and same qualifications as Original Medicare.
- MAPD can’t do “funny stuff” or they can get busted for Risk Adjustment Fraud
- Sample Medi Gap
- All costs for each day after day 100 in a benefit period Medicare.Gov SNF *
Medicare doesn’t cover long-term care or custodial care.
Medical Requirements
The beneficiary needs daily skilled care or rehabilitation services as ordered by a physician. These skilled services can only be rendered by, or under the direct supervision of, skilled nursing or rehabilitation staff. In addition, the skilled services the patient receives must be for a medical condition they were treated for during the three-day qualifying hospital stay, or for a condition that arose during that hospital stay or while the patient was receiving Medicare-covered SNF care.
The requirement of “daily” skilled services should not be taken so literally that occasional sessions missed due to holidays or illness will make the patient not meet the daily requirement for skilled services.
See Oscar’s Clinical Guidelines – It’s explained so much better!
30.6 – Daily Skilled Services Defined
Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7-days-a week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. (If therapy services are provided less than 5 days a week, the “daily” requirement would not be met.)
EXAMPLE:
A patient who normally requires skilled rehabilitation services — See Medicare Benefit Policy Manual Chapter 8 –Coverage of Extended Care (SNF) Services Under Hospital Insurance
Don’t qualify for Skilled Nursing?
Check out the True Freedom Home Health Plan – BEFORE you need it.
Resources & Links
- Skilled nursing facility care coverage (Medicare.Gov)
- Get help paying for skilled nursing facility care
- Medi Cal IHSS In Home Services
- Medi Cal – Medically Needy – Share of Cost
- Medi Cal – Qualification & Estate Recovery
- Medi Cal has 90 day look back on claims from date you applied
- Our webpage on Home Health & Long Term Care
- 7 ADL’s Activities of Daily Living to trigger Long Term Care
- Veterans Administration?
- Find hospitals & skilled nursing facilities
- Booklet on this page to finding Nursing Homes
- medicare.gov/-skilled-nursing-facilities
- Pamphlet on Skilled Nursing from Medicare
- Hospice, Palliative & Respite Care
- Medicare Benefit Policy Manual Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance
- Social Security – Benefits for Surviving Spouse & Dependent Children
Authorized Agent
Email us [email protected]
Medicare Coverage for #SkilledNursing - 10153
Our Introductory You Tube VIDEO based on this manual
(Clinical Guidelines Explained so much better and in logical order!)
VIDEOs
- Medicare's VIDEO Nursing Home / Long-Term Care
- Our Webpage on Long Term Care
Medicare #Appeals 11525
Filing an appeal with Medicare
- Official Medicare Advantage Plan Appeals VIDEO
- How to Appeal a Denial of your Health Claim - VIDEO Kantor & Kantor Attorneys
- Medicare Rights - Appeals VIDEO
- See our webpage on
- Appeals & Grievances
- Medicare Appeals
- Attorneys - We don't know them... Found on Google
- Green Associates
- Chapman Law Group
- Appeals & Grievances
- See our webpage on
Home health services
You can use your home health benefits under Part A and/or Part B to pay for home health services. Medicare covers medically necessary part-time or intermittent skilled nursing care, and/or physical therapy, speech-language pathology services, or continued occupational therapy services. A doctor, or certain health care professionals who work with a doctor, must see you face to-face before a doctor can certify that you need home health services. A doctor must order your care, and a Medicare-certified home health agency must provide it.
Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means:
• You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
• Leaving your home isn’t recommended because of your condition.
• You’re normally unable to leave your home because it’s a major effort.
You pay nothing for covered home health services. You pay 20% of the Medicare-approved amount, and the Part B deductible applies, for Medicare covered medical equipment. copied from Medicare & You – see brochure in side panel *
Skilled Nursing Official Booklet
Home Health Official Booklet
True #Freedom Plans
"Prepaid Home Health Care?"
Watch 3 minute simple plain English Video
- Email us for more information [email protected]
- Our webpage on Long Term & Home Health Care
- Our webpage on True Freedom
Medicare & #HomeHealth Care # 10969
Check out
TRUE FREEDOM - Home Health Care
No health questions asked
Our webpage on Home Health & Long Term Care
Here’s the Medicare.Gov Nursing Home finder, guide & Comparefor the Los Angeles South Bay area, California and Nationwide.
This government provided tool also allows you to see what insurances and public benefits are accepted at the various facilities.
Medicare –
Private – Individual Long Term Care Coverage.
Here’s a 7 page Checklist to help keep track in your search. Hopefully, you don’t need all the services of a nursing home here’s Alternatives to Nursing Home Care.
We’ve also included all the helpful and relevant publications and information we could find on this page and others in this website. Use the menu at top or embedded links to navigate and find the information that you need.
Resources & Links
Veteran’s Home Health Care va.gov
Veteran’s Care Co-Ordination.com
Intake form for Aid & Attendance
Health Grades.com – they charge a fee
Poorest Nursing Homes
Medicare.Gov Home Health Compare
Prevent & Report Elder Abuse CA Attorney General
Law Help Nursing Homes & Residential Care Facilities Nursing Home Bill of Rights CA Deptment of Public Health pdf 39 pages
Code of Federal Regulations (C.F.R.), 42 CFR 483.12
Physician’s Report for Residential Care Facilities for the Elderly (RCFE) Preplacement Appraisal Information LIC 603 Identification and Emergency Information LIC 601 Senate Reviews Assisted Living Facility Problems 2.2014 CA Health Line
Publications
See our Resources and Introduction Page for more information on Long Term Care Coverage, What Medicare Provides, Medi-Cal – Medicaid, Veterans, etc.
Pending Legislation
SB 411 2012 – Price – Licensing of Home Care Agencies & Workers AB 889 Ammiano – 2012 Domestic Workers New Life Styles.com – The source for Senior Living
How to Find Home Health Care
-
Senior Living and Care Options –
- New Life Styles.com
24 hr cares.com Home Care Provider – owned by the son of a friend of ours
Continuing Care Retirement Communities (CCRCs)
offer persons 60 years of age or older a long term continuing care contract that provides for independent living units, residential care/assisted living services, and skilled nursing care, usually in one location, and usually for a resident’s lifetime. Most CCRCs require a substantial entrance fee (e.g., from a low of $100,000 to over a million) to be paid by the applicant upon admission along with monthly fees. * CANHR.org *
Help!
I need Skilled Nursing Care, but my Medicare Advantage Plan, Medicare and Livanta the Medicare reviewer – appeals board say I don’t. What can I do? Here’s an excerpt of my denial letter.
Can you get your MD to review the appeal denial and use the Medical Necessity Clinical Guidelines and go step by step and show the evidence in the medical records that you need skilled nursing care and services on a daily basis to maintain or prevent decline?
To help you transition to a lower level of care?
How about Medicare’s Home Health Care benefits? Can you get your doctor to write up a program of care that meets the Home Health Care guidelines?
Medi Cal IHSS In Home Supportive Services?
My Dad needs “sub acute care” as opposed to SNF Skilled Nursing Facility – what do we do?
We just worked on a client with a similar situation…. Here’s links & references:
CA Department of Health Care Services — Sub acute Care
In home supportive care Medi Cal – Medicaid
Physical therapy Medicare Rules…
Medicare Website Skilled Nursing SNF
Our Webpage Medicare Skilled Nursing & Home Health Care
Requirements to qualify for Skilled Nursing Care
Physical & Speech Therapy
Requirements for Physical & Occupational Therapy
Medicare.Gov MAPD Medicare Advantage Plans must cover all Medicare Services!
Medicare Quality of Care Complaint Form
Medi-Cal Medicaid Long Term and Nursing Home coverage – Estate Recovery
Medi Cal Medicaid Share of Cost
Risk Adjustment Fraud
Livanta – Medicare Contractor to make sure MAPD meets Medicare guidelines
Our webpage on Long Term Care
Our webpage on Blue Shield Medicare Advantage
If we change plans by March 31 for MAOEP Medicare Advantage Open Enrollment Period, can we get a secondary or supplemental plan to pay for Long Term Care, Sub Acute Care or the $185 Skilled Nursing Co Pay?
Not that I’m aware of.
Insurance Companies need to make a profit and take in 20% more than they pay out in claims. Medical Loss Ratio and all.
First, let’s define and figure out what “sub acute” means.
What is Subacute Level of Care?
Subacute patients are medically fragile and require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, and complex wound management care.
Adult subacute care is a level of care that is defined as comprehensive inpatient care designed for someone who has an acute illness, injury or exacerbation of a disease process.
Pediatric subacute care is a level of care needed by a person less than 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. DHCS Medi Cal *
Provider criteria for participation in the Subacute Care Program:
Licensed as an acute care hospital with a distinct part (DP), skilled nursing facility (SNF), or
Licensed as a freestanding (FS) SNF, and
Certified as a long term care Medicare and Medi-Cal provider, and
History of compliance with the DHCS Licensing and Certification program, and
Professional staff with the ability to provide care to subacute patients either by experience or demonstrated competence.
When a provider meets the criteria the DHCS enters into a contractual agreement to provide services to Medi-Cal subacute patients.
When a DP/FS SNF meets the criteria the DHCS enters into a contractual agreement, with the facility, to provide services to Medi-Cal subacute patients. DHCS Medi Cal *
Medi Cal sub acute care program, eligibility and treatment procedures
When you are ready to leave the hospital, you may need more medical care and rehab as part of the next step before you can go home. Your Cedars-Sinai care team may arrange for you to go to a sub-acute unit at a nursing facility while you are still healing and getting your strength back. Cedars Sinai *
Sub acute rehab (also called subacute rehabilitation or SAR) is complete inpatient care for someone suffering from an illness or injury. SAR is time-limited with the express purpose of improving functioning and discharging home.
SAR is typically provided in a licensed skilled nursing facility (SNF). SAR is typically paid for by Medicare or a Medicare Advantage program.
SAR provides help in two different areas:
Licensed physical, occupational and speech therapists provide therapy to increase your strength and functioning. For example, depending on what your need is, they might work to:
Increase your balance
Improve your safety when walking
Work to help you move your legs again after a stroke
Improve your independence with activities of daily living (ADLs)
Improve your cardio (heart) fitness after a heart attack
Licensed nursing staff provides medical care such as:
Wound management
Pain management
Respiratory care
Other nursing services that must be provided or supervised by an RN or LPN
SAR vs. Acute Rehab vs. Hospital
The terms used to talk about medical care and rehabilitation can be confusing at times. SAR is different from a hospital or an acute inpatient rehabilitation center.
A hospital, which is sometimes called “acute care,” is appropriate only for significant medical issues with the goal of a very short stay.
An acute rehab center is designed for high-level rehab needs, typically requiring more than three hours a day of physical, occupation, or speech therapy.
Sub acute rehab (SAR) centers are usually most appropriate for people who need less than three hours of therapy a day, thus the label of “sub acute,” which technically means under or less than acute rehab. Very Well.com * knollwood *
Help!
I’ve been in the hospital, skilled nursing, etc. since November. Due to an infection my toes were amputated. I need physical therapy, skilled nursing, home health care, Medi Cal, IHSS, I don’t know what all.
What programs and guarantees are available to me.
I also have Blue Shield 65 Plus HMO, how is it better and differ from original Medicare?
Here’s our webpage on physical therapy
Here’s the EOC Evidence of Coverage for Blue Shield 65 Plus
Please note that MAPD Medicare Advantage plus must give you equal or better benefits than original medicare!
Skilled Nursing
Note – Medicare is $185/day co-pay for days 21 to 100.
Home Health Care Agency
See the brochure above on Medicare eligibility and benefits of Home Health Care
See the Blue Shield EOC for their rules, details and appeals process. Try Ctrl – F to search.
Skilled Nursing not medically necessary
See above for the Medicare Pamphlet & Video on Home Health Care
Medi Cal Aged & Disabled Program
Medi Cal IHSS In Home Supportive Services
Appeals & IMR Independent Medical Review
Do ObamaCare/ACA policies cover Skilled Nursing? How long?
Skilled Nursing Facility Benefits
Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a freestanding Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits.
The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded.
A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received.
A new Benefit Period can begin only after an existing Benefit Period ends Specimen Policy
Summary of Benefits
Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period,
Here’s the best explanation that we found on Nolo’s website.
What about “Rehab?”
Here’s the best explanation that we found on Nolo’s website.