In the United States, Medicare is a health insurance program for people 65 and older (as well as those with specified medical conditions). Hospital stays, outpatient services, and preventive care are all covered under the program. Also, when a person needs specialized care, Medicare may fund short-term stays, called the Medicare nursing home facility.
However, if a person wants to stay in a nursing home for an extended period, Medicare usually does not pay this expense.
When does Medicare pay for treatment in a nursing home?
It’s sometimes easier to grasp what Medicare covers at a nursing home by first understanding what it doesn’t cover. When a person merely needs custodial care, Medicare does not cover the cost of care in a nursing home. The following services are included in custodial care:
- Using the toilet
In general, if a person needs care that does not require a degree to perform, Medicare will not pay for it.
Let’s take a look at what Medicare does and does not cover.
It’s also worth noting that this is only a short-term solution, not a long-term solution.
In most cases, Medicare Part A will cover up to 100 days of treatment in a skilled nursing facility. The person must be admitted to a skilled nursing facility within 30 days of leaving the hospital, and they must be admitted for the disease or injury for which they were getting hospital care.
What parts of Medicare pay for nursing home care?
Short-term skilled nursing care at a nursing home is usually solely covered by Medicare. Continue reading to learn more about what Medicare may cover in terms of nursing homes.
Part A of Medicare
In a nursing home, Medicare Part A may cover the following services:
- Nutritional guidance and services
- Medical equipment and supplies
- Occupational therapy services
- Rehabilitative treatment
- A semi-private room
- Competent nursing care, such as changing wound dressings
- Social work services relating to medical treatment that is required
- SLP (Speech-Language-Pathology)
Swing bed services are an example of a service that Medicare might cover. However, professional nursing facility care is provided when a person obtains skilled nursing facility care in an acute-care hospital.
Part B of Medicare
Outpatient treatments, such as doctor visits and health screenings, are covered by Medicare Part B. Nursing home stays are frequently not covered by this part of Medicare.
Is it covered in any way by Advantage plans?
Medicare Advantage plans (commonly known as Medicare Part C) typically do not cover custodial care in nursing homes. A few exceptions exist, such as if a person’s plan includes a contract with a specific nursing facility or nursing home-operating organization.
Before visiting a nursing home, check with your plan provider to see what treatments are not covered under your Medicare Advantage plan.
What about supplements for Medigap?
Private insurance firms sell Medigap supplement policies, which help to pay additional costs like deductibles.
Some Medigap plans may cover Coinsurance for skilled nursing facilities. Plans C, D, F, G, M, and N. Plan K covers approximately half of the Coinsurance, whereas Plan L covers the other.
Long-term nursing home care, on the other hand, Medigap supplement insurance.
What about drugs prescribed under Part D?
Prescription drug coverage under Medicare Part D helps pay for all or a portion of a person’s prescriptions.
Suppose a person resides in a nursing home. In that case, their prescriptions are usually filled by a long-term care pharmacy specializing in pharmaceuticals for people in long-term care facilities like nursing homes.
If you’re receiving skilled nursing care in a skilled facility, Medicare Part A will generally cover your prescriptions during this time.
Which Medicare plans should you choose if you require nursing home care in the coming year?
The majority of Medicare plans do not cover nursing homes. If you enroll in a Medicare Advantage plan through a special arrangement with a nursing facility, you may be eligible for an exemption from the rule on enrollment. This is the exception rather than the rule, and the alternatives vary depending on the region.
What is home nursing?
A nursing home is a facility where patients can receive additional care from nurses or nurse’s aids.
Many of these facilities are likely to be homes or apartments for persons who require further assistance with daily activities or no longer wish to live alone. Some provide rooms with beds and showers and common areas for classes, recreation, eating, and relaxing, similar to hospitals or hotels.
Most nursing facilities give care 24 hours a day, seven days a week. Services may include aid with going to the restroom, prescription assistance, and meal services.
What is the cost of nursing home care?
From 2004 to 2019, the financial firm Genworth examined the cost of care in skilled nursing institutions and nursing homes.
They discovered that the average cost of a private room in a nursing home in 2019 is $102,200 per year, up 56.78% from 2004. The average cost of care in an assisted living facility is $48,612 per year, up 68.79% from 2004.
Nursing home care is expensive; rising prices are attributed to the treatment of increasingly sicker patients, employee shortages, and increased restrictions, all of which drive up the cost of providing care.
The bottom line
If a person satisfies specific criteria, Medicare Part A may cover skilled nursing care in a nursing home setting.
If you or a loved one wants or needs to live in a nursing home for a long time to receive custodial care and other services, you’ll almost certainly have to pay out of cash or rely on long-term care insurance or Medicaid.
For more assistance, visit NewMedicare.com.