Many people are under the misperception that Medicare will pay for nursing home care. Medicare, the federally funded health insurance received upon attaining 65 years of age, will only pay for skilled nursing care under certain circumstances and then only for a limited period of time. When you have been discharged from a hospital stay of at least three days to a Medicare-approved skilled nursing facility, and if you require “skilled” care for treatment of the condition for which you were hospitalized, Medicare will pay 100% of the cost of your care for up to twenty days. From the twenty-first day through the one hundredth day, Medicare will pay any amount due over $174.00 per day (2020 figure). Medigap insurance may cover the co-insurance payment. But keep in mind that Medicare only pays as long as your required “skilled” nursing care – that is, care under the daily supervision of a doctor, registered nurse, physical therapist or other licensed professional. After the one hundred days, Medicare pays nothing towards cost of the nursing facility.
A new spell of illness can begin if the patient has not received skilled care, either in a skilled nursing facility (SNF) or in a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care during that 60 days.
Denial of Medicare coverage to skilled nursing facility patients
Nursing homes often terminate Medicare coverage for skilled nursing facility care before they should. Two misunderstandings most often result in inappropriate denial of Medicare coverage to skilled nursing facility patients. First, many nursing homes assume in error that if a patient has stopped making progress towards recovery then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain his or her status (or to slow deterioration) then the care should be provided and is covered by Medicare.
When a patient leaves a hospital and moves to a nursing home that provides Medicare coverage, the nursing home must give the patient written notice of whether the nursing home believes that the patient requires a skilled level of care and thus merits Medicare coverage. Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will issue a “Notice of Non-Coverage” terminating the Medicare coverage.
Whether the non-coverage determination is made on entering the SNF or after a period of treatment, the notice asks whether the patient would like the nursing home bill to be submitted to Medicare despite the nursing home’s assessment of his or her care needs. The patient (or his or her representative) should always ask for the bill to be submitted. This requires the nursing home to submit the patient’s medical records for review to the fiscal intermediary, an insurance company hired by Medicare, which reviews the facilities determination.
If the fiscal intermediary upholds, the denial, an additional appeal can be made to an Administrative Law Judge. Whether an additional appeal should be taken required greater scrutiny. If the appeal is denied, the patient will owe the nursing home retroactively for the period under review. In a next blog, we will review alternatives to paying privately in a nursing home if Medicare coverage has ended.
by Jerold E. Rothkoff, Esq. Managing Attorney, Rothkoff Law Group
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