What Is Covered?
If you currently have Medicare coverage, your stay at a Skilled Nursing Facility will have most of your costs covered. Medicare will pay for a semi-private room, meals, nursing care, drugs, supplies, appliances, equipment, and routine labs and x-ray services. Medicare does not cover personal or convenience services such as beauty services, telephone, etc. Depending on your need, you may utilize different types of Medicare also known as “parts.”
Medicare Part A (hospital insurance): This covers inpatient hospital care, skilled nursing home care, hospice care, and some home health care. Also covers charges incurred for room and board.
Medicare Part B (medical insurance): This covers doctor’s visits, outpatient care, and other medical services. Does not cover charges incurred for room and board, but does cover some therapy charges with a Part B co-pay.
Do You Qualify?If you are not sure if you qualify for Medicare, these guidelines can serve as a simple litmus test to see if you could be covered by Medicare.
- You are age 65 or older and you are eligible to receive Social Security Retirement, Survivor's benefits, or Railroad Retirement Board Benefits.
- You are under age 65 and you are entitled to receive Social Security Disability benefits or Railroad Retirement Board disability benefits, and have been entitled to those disability benefits for at least 24 consecutive months.
- You are under the age of 65 and you have End Stage Renal Disease requiring dialysis or kidney transplant. You must be receiving or are eligible for Social Security Benefits or are the spouse or dependent child of someone who is insured for benefits. You will need Part A and Part B in order for Medicare to cover certain dialysis and kidney transplant services.
RequirementsIn order to qualify for Medicare coverage in a skilled nursing facility you must fulfill certain criteria. Those are:
1.) You must have Medicare Insurance. Medicare Insurance is available to those people that are 65 years or older and/or those that are disabled.
2.) The facility must have a skilled nursing bed that has been Medicare certified.
3.) You must be admitted to the facility within 30 days of a qualifying stay in the hospital of 3 consecutive midnights or more.
4.) You must require daily skilled nursing care or skilled therapy services as certified by a physician. Examples of skilled care include therapy, tube feedings, IVs, pain management, medication monitoring, etc.
5.) Inpatient Observation status does not qualify as a Medicare stay regardless of the number of nights spent at a hospital.
Pay RatesDays 1-20 - Medicare pays 100%
Days 21-100 - Medicare pays all but daily co-payment with the resident responsible for daily co-payment portion.
Days 101 and After - Resident is responsible for 100% if no private insurance or Medicaid is available
Co-Payment Options1. Private Insurance – Most health insurances will not cover a long term care stay unless you have long term care policy coverage.
2. Private Pay (Out of Pocket)
Re-Qualification RequirementsIf you have recently used your Medicare coverage for a stay in a skilled nursing facility, there are certain criteria that must be fulfilled before you may re-qualify for additional Medicare coverage.
1. You must be admitted within 30 days of a qualifying stay in the hospital of 3 consecutive midnights or more.
2. You must require daily skilled nursing care or skilled therapy services as certified by a physician.
3. You must have had a 60 day break between Medicare stays and spells of illness and not in a certified Medicare bed.
If you have questions about your Medicare coverage, do not hesitate to call our Medicare experts at 816-324-3185, ext 140.