February 26, 2013

Planning Ahead: Medicare Does Not Cover Nursing Home Long Term Care

by Lebowitz & Mzhen

When we talk about nursing homes, we must differentiate between whether we are referring to a short term stay related to medical care, such as in a rehabilitation care facility, or rather we are discussing a residential stay. The latter, which involves living in a nursing home or assisted living facility, is properly referred to as "long term care."

nursing%20home%20room.jpgMany people mistakenly believe that Medicare will pay for this long term care because Medicare willpay for skilled rehabilitation care within a Skilled Nursing Facility (SNF). However, there are strict requirements for when Medicare benefits will cover skilled care within a SNF. If you meet certain eligibility and Medicare plan requirements, then you may be able to have up to 100 days of care (per benefit period) in a SNF covered by your Medicare Plan. You will want to check with your plan, as a co-payment may be required after a certain number of days.

Medicare will cover skilled care only if all of the following are true:


  • You have the Medicare Part A (hospital insurance);

  • You have days left within your current benefit period available to use;

  • You have a qualifying hospital stay-- more than 3 days excluding discharge (and with other limitations), and you enter the SNF within 30 days of discharge;

  • Your doctor orders the services of a SNF, which require the skills of trained professionals, such as occupational therapists, registered nurses, speech therapists, etc.;

  • You require the skilled care on a daily basis, and those specialized services are such that they can only be conducted on an inpatient basis;

  • You need the skilled services for a medical condition that was either (1) treated during your qualifying 3 day hospital stay; or (2) began while you were already staying in a SNF for a medical condition arising out of the hospital stay. (For example, the original stay in the SNF was for surgery, but you suffered a stroke while in the SNF);

  • The skilled services must be both reasonable and necessary, in terms of the diagnosis or treatment for your condition; and

  • You can get these skilled services in an SNF that is certified by Medicare.

It is important to keep in mind, however, that once a patient is eligible for SNF coverage, it does not mean that coverage will continue. If a patient refuses his or her daily skilled treatment or care, they may lose their Medicare SNF coverage.

Beyond the qualified types of stay as outline above, if a person does not have special long term care insurance, they will have to pay out of pocket for an assisted living facility or nursing home. The average cost for an assisted living facility in Maryland is estimated at upwards of $49,000, with the cost of a nursing home estimated at around $85,000 per year.

If you do not have a long term care insurance policy, and you need help paying for a nursing home or assisted living facility, you may be eligible for Medical Assistance for Long-Term Care. This program evaluates financial statements for past years, and evaluates a patient's physical condition. If a person qualifies, this can help offset the cost of care.

Maryland has a Medical Assistance Waiver program to help in state residents that need help paying for care. You can find more information on the organization's website. You can also find
additional information on Skilled Nursing Facilities and coverage under Medicare.

At Lebowitz & Mzhen, our nursing home lawyers help residents and their families in Maryland obtain compensation for injuries caused by abuse or neglect. To schedule a free and confidential consultation, contact us today online or at (800) 654-1949.

More Blog Posts:

Nursing Home Closes Amid Allegations of Abuse, Neglect, and Other Deficiencies, Maryland Nursing Home Lawyer Blog, published February 12, 2013

Study by Federal Regulators Finds Higher Rate of Medicare Fraud Among For-Profit Nursing Homes, Maryland Nursing Home Lawyer Blog, published February 5, 2013

Does Quality of Care Differ Between For-Profit and Non-Profit Healthcare Facilities?, Maryland Nursing Home Lawyer Blog, published January 9, 2013