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:

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. 

 

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 *

Learn more 

Skilled Nursing Official Booklet

Home Health Official Booklet

Finding and #Choosing the right Nursing Home for you or a loved one 

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.

Medi-Cal,

Medicare –

Skilled Nursing, Publication

Home Health Care

Private – Individual  Long Term Care Coverage.

Employer

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

Jewish Free Loan Assoc.

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

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  *

 

Continuing Care Retirement Communities

20 comments on “Skilled Nursing SNF & Home Health What Medicare Pays

  1. 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.

    A review of the medical record shows that the patient was admitted to the skilled nursing facility after hospitalization for difficulty breathing and weakness.

    The patient is now receiving skilled services for decreased functional mobility. The patient has made poor progress and is unable to
    walk, needing help for bed mobility and transfers. The patient needs moderate help for upper body dressing and totally dependent for lower body bathing, toileting and lower body dressing.

    There is no documented evidence that continued skilled services are needed on a daily basis to maintain or prevent decline.

    There are no documented medical issues to support the need for daily skilled nursing care.

    • 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 *

  2. 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?

    • 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,

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