What are Your Options when Medicare Stops Paying for Nursing Home Care

source: US News & World Report - link & credits below

October 7, 2022


Photo credit: Chatterbox Multi Media


For a limited amount of time, Medicare pays for skilled nursing care, which includes medical care, physical and occupational therapy and other services, for individuals who qualify.

It’s important to keep in mind that Medicare is a form of health insurance, it's not meant to cover housing and food costs or long-term stays in a nursing facility.


What happens when Medicare stops paying for skilled nursing care? Some people who recover quickly and fully can go back to how their lives were before. But many people will need some kind of continuing care.


What Is Skilled Nursing?

Skilled nursing is not a form of long-term care and isn't a permanent residence. Rather, skilled nursing provides complex care and rehabilitation for people who have had a stroke, surgery or extensive treatment for kidney, heart or respiratory conditions and may need rehabilitation after their release from a hospital stay. However, some long-term nursing homes have wings in the same building where they provide short-term skilled nursing care, says Salama Freed, an assistant professor of health policy and management at the Milken Institute School of Public Health at George Washington University in Washington, D.C.


Long-term care, on the other hand, such as the services provided by nursing homes, is appropriate for seniors who need around-the-clock care for conditions such as the debilitating effects of a major stroke or dementia, chronic medical conditions and limited mobility. Basically, people who have conditions that compromise the activities of daily living.


What happens when Medicare stops paying for skilled nursing care? Some people who recover quickly and fully can go back to how their lives were before. But many people will need some kind of continuing care.


People who need skilled nursing care can get 100% of the cost covered by Medicare for the first 20 days of their skilled nursing care and 80% for up to 80 days after that – if they qualify. Medicare will cover a maximum of 100 days of skilled nursing care, and most individuals leave a residential skilled nursing site well before that, says Linda Lateana, chief operating officer at Goodwin Living, a not-for-profit, faith-based regional senior living and health care services organization in the national capital region. Goodwin Living manages and operates three senior living communities in Northern Virginia.


Who Qualifies?

There are specific requirements individuals have to meet to be eligible in order to be covered for Medicare skilled nursing care, Lateana says.

Here are some of the ways you can qualify for Medicare part A (hospital insurance) coverage for skilled nursing care, according to medicare.gov:

Your physician determines you need daily skilled nursing care.

  • You’ve had a hospital stay of at least three days (not including the day you leave the hospital).

  • You need skilled nursing services for a hospital-related medical condition (like an infection) that you were treated for during your qualifying three-day inpatient hospital stay, even if it wasn’t the reason you were admitted.


A facility that offers skilled nursing care offers these services:


  • Medically-necessary care that can only be provided by a licensed medical personnel. This could include intravenous injections, wound care and catheter care.

  • Rehabilitation services, including physical, occupational and speech therapy. These services are needed by patients who have suffered a stroke, broken bones or a traumatic brain injury. These services are also needed for patients who’ve undergone heart surgery, back surgery or have had a hip or knee replacement.


Continued Home Health Care

Many people who leave a skilled nursing home after two or three weeks will need a continuation of services, says Karen Doyle, associate executive director at Goodwin House Bailey's Crossroads, a Goodwin Living Life Plan Community. Such services are often referrals that are part of a formal discharge plan from a skilled nursing facility. While Medicare will only cover up to 100 days at a skilled nursing facility, it usually provides coverage for an array of home health services, she says.


There's no limit on how much Medicare pays for medically-necessary outpatient therapy services, such as occupational or physical therapy, in a calendar year.

After you pay the Medicare Part B deductible, which is $226 for 2023, you'll pay 20% of the Medicare-approved amount for the service. The amount an individual will pay depends on a variety of factors, such as whether the patient has other insurance and where he or she obtains the services.

Those services include:

A nursing assistant to help the patient shower twice a week.

  • Occupational therapy. Medicare will cover occupational therapy either in a skilled nursing facility or in the patient's home (including independent living, assisting living, memory care and nursing home settings) with services provided by a certified home health agency. Occupational therapy helps patients conduct the daily tasks of living, such as dressing and bathing.

  • Physical therapy. Medicare will cover physical therapy in a skilled nursing home or a patient's home, including independent living, assisted living and nursing home settings, the the patient is receiving it from a Medicare-certified home health agency. The aim of physical therapy is to evaluate and treat disease and injuries that change your ability to function.

  • A nurse to help with the administration of medication.

  • A social worker. If the patient doesn't have a relative or loved one who can help coordinating their care, a social worker can fill that role.


A Growing Need for Long-Term Care

A solid majority of U.S residents will at some point need some kind of long-term care. Overall, 70% of people currently age 65 or older will need some kind of long-term care, according to the federal government. What’s more, 20% of people in that demographic will need such care for more than five years, according to LongTermCare.gov.


If you need continued care after your Medicare coverage for a rehabilitative skilled nursing stay ends, you have various at-home and residential options that you can pay for with private funds until they are exhausted, then apply for Medicaid, Doyle says. If you have no assets, you can apply for Medicaid. Medicaid is the joint federal-state insurance program that offers health coverage to eligible low-income seniors. Obtaining Medicaid does not preclude someone from using Medicare; Medicaid bolsters Medicare coverage for those who qualify.


During your initial hospital stay of at least three nights, which is required to become eligible for Medicare to cover your stay at a skilled nursing facility, hospital staff can help you see if you qualify for Medicaid. “You can ask the hospital to do your initial Medicaid pre-screen,” Doyle says.


Unlike Medicare, Medicaid is administered by the states, with 50 sets of often complex rules and requirements.


For those who have it, private long-term care insurance can help you pay for nursing home care, says Jay Zigmont, founder of Childfree Wealth, which provides life and financial planning services. He's based in Water Valley, Mississippi. Keep in mind that most long-term care insurance plans are reimbursement policies. Long-term care insurance is private insurance that helps people cover the costs of long-term care for a chronic illness or other serious condition, like the effects of a stroke, in a facility like a nursing home. Like other types of insurance, you typically purchase it by paying monthly premiums.


“In a reimbursement policy, you must pay the bill first, and then the insurance will pay you back,” he says. Such policies are based on a daily or monthly maximum amount of coverage, and the number of years that will be covered. Most such policies can be used for in-home services, assisted living or skilled nursing services. “Having the flexibility to pay for all types of care is important,” he says.

Traditional nursing homes are often not part of a continuing care community, which typically offer a range of living arrangements with varying levels of services, including:

Independent living

Single people or couples live independently in their own apartments in a retirement community. Independent living communities often offer wellness and recreation programs and local transportation to activities, shopping and errands.

Memory care

This type of care involves a long-term care facility that offers specialized services for individuals with dementia, including Alzheimer’s. Staff members are trained to work with people with dementia, and specialized care is provided around the clock.

The costs of each of these memory care communities vary from region to region. If individuals or couples own a home, they could sell it and use the proceeds to help pay for the costs of living in a continued care community. Prices tend to be higher in urban areas where the cost of housing is higher.


At two of the Goodwin Living communities, Goodwin House Alexandria and Goodwin House Bailey's Crossroads, there’s a one-time entrance fee ranging from $66,000 to more than $1 million for independent living, as well as monthly fees ranging from $4,000 to $12,000 per month, depending on the apartment size and type of contract (Goodwin Living has five different contracts).


For assisted living and memory care, monthly fees range from $8,200 to $11,000 a month. For skilled nursing care, the price is about $17,000 a month.

Nursing care services

Continuing care communities provide within their setting nursing care services, which entails services similar to those that would at a traditional nursing home.

Other options for seniors include:

Assisted living

This type of setting is for people who need assistance with the activities of daily living, like bathing, dressing, preparing meals, doing laundry and medication administration. In an assisted living community, for example, a nurse could help residents with their medications. Certified nursing assistants in some states can also provide help with personal care needs, such as bathing and dressing.

Nursing homes

A nursing home is a residential center that can provide care for seniors who are medically stable but aren't able to live at home because of mobility issues or chronic health conditions that interfere with their activities of daily living. Frailty can also be such a condition.


There are about 1.7 million nursing home beds in the U.S. in 15,600 facilities, according to the Centers for Disease Control and Prevention. The demand for nursing care is expected to rise in the coming years. People aged 65 and over comprise 16.8% of the country's population, according to the 2020 U.S Census.


The U.S. population is aging rapidly, demographers say. By 2030, all baby boomers will be 65 years or older, according to the U.S. Census Bureau. Nursing care is pricey. The national annual median monthly cost of nursing care is $8,700 a month for a private room and $7,800 a month for a semi-private room, according to the Cost of Care Survey 2021 by Genworth Financial.

Both assisted living and nursing care settings provide activities of daily living support. The difference is the level of need a resident has. If the need is higher, then that support is best provided in a nursing care setting. If the need is lighter, care needs might be met by an assisted living setting.


SOURCE: https://health.usnews.com/best-nursing-homes/articles/when-medicare-stops-paying-for-nursing-home-care


Karen Doyle, MSN, LNHA, HSE Doyle is associate executive director at Goodwin House Bailey's Crossroads, a Goodwin Living Life Plan Community.

Salama Freed, PhD Freed is an assistant professor of health policy and management at the Milken Institute School of Public Health at George Washington University in Washington, D.C.

Linda Lateana, MSW, LNHA Lateana is chief operating officer at Goodwin Living, a not-for-profit, faith-based regional senior living and health care services organization in the national capital region.

Jay Zigmont, PhD Zigmont is founder of Childfree Wealth, which provides life and financial planning services. He's based in Water Valley, Mississippi.