My mom is in skilled nursing, will need transfer to another one long term. She has a good private health insurance through AARP, no long term care insurance and can't return home to live due to medical issues that have developed since a stroke. She has recently developed pneumonia as well.
I keep hearing about "100 days" and a patient is out of skilled nursing with medicare. Medicaid sounds like a nightmare, financially and other wise. We live in California and I don't even know where to start with the idea of what to do next.
Any experience with this? Suggestions?
Thanks!
Medicare Coverage of Nursing Home Expenses
Many clients are under the mistaken impression that Medicare will cover their long-term nursing home stays. If you give seminars or in client meetings, it is important that you educate the lay public about this.
In order for Medicare to cover a person’s nursing home stay, the patient must:
1. Have been hospitalized for medically necessary inpatient hospital care for at least 3 consecutive days, not counting the date of discharge,
2. Be admitted to the nursing home within 30 days after the date of discharge from the hospital,
3. Require skilled (as opposed to custodial) nursing or rehab care on a daily basis for a condition for which the patient was hospitalized, and
4. Receive a physician’s order that such care is needed.
Skilled Care. Skilled care is care that can only be administered by professional (physician or nurse) or technical personnel and which will prevent further deterioration in the patient’s health. Examples are intravenous feeding, injections, insertion of catheters, application of sterile dressings, treatment of skin ulcers, and therapeutic exercises of various kinds. Less medically intensive and critical personal care services, even if done by a nurse, are not considered skilled care.
100-Day Limit. Once in the nursing home, the patient will only be covered by Medicare for a maximum of 100 days during any spell of illness. A “spell of illness” means a period of consecutive days beginning with the first day (not included in a previous spell of illness) on which such individual is furnished inpatient hospital services, inpatient critical access hospital services or extended care services, and which occurs in a month for which he is entitled to Medicare Part A benefits, and ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of a nursing facility.
Co-Pay Rule. Finally, even if the patient manages to qualify for Medicare coverage of their nursing home stay, Medicare only fully pays the bill for days 1-20. For days 21-100, Medicare only pays the “SNF care coinsurance” amount, which in 2010 is $137.50 (set annually by the federal government).
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Hope that helps!
K. Gabriel Heiser
Thank you for taking the time to respond. My mother contracted pneumonia ,swollen right extremities and developed skin ulcers in the nursing home.Mild heart failure was diagnosed on the Xray which showed no progress was being made with curing the pneumonia. So, my mom started out in the facility because of rehab needs after a stroke and now there are many complications to both general health and viable rehab progress.
Does she need to be reevaluated and diagnosed with multiple needs for"skilled" nursing?
If she left skilled nursing, went back to the hospital for 4 days for heart failure then back to rehab would the 100 days start again?
Any suggestions are very much appreciated.
Thanks again for sharing your expertise.
Kim(caremom1)
Based on the "100-Day Limit" paragraph, above, it appears that she would have to be neither an inpatient of a hospital nor an inpatient of a nursing facility for at least 60 days before the next 100-day period can start.
Medicare does not pay for long term care, but rehabilitative care in a skilled nursing facility and is limited to 100 days only. You can take advantage of the first 20 days because medicare pays every cent of your expense but after 20 days, you need to shoulder some of your expenses until the 100 day period. After 100 days, you will shoulder all your expense out of pocket. To be able to qualify for medicare, you should be 65 years old or above, but if you have disability or kidney disease, you still qualify for medicare even if you are younger than 65.
Medicaid is a program that pays for long term care expenses, however, you should pass a poverty criteria to qualify. The poverty criteria depends on the state where you live. Although medicaid covers your expenses for long term care services, they have an asset-recovery procedure, in the event that an individual under medicaid program dies, their property will be subjected to this procedure so medicaid can recover the expenses incurred for the person's ltc services.
Private insurance on the other hand offers long term care insurance to finance your long term care needs, however, if you already have an illness, you might be declined. You cannot insure a person who is already ill just as you cannot insure a house that is already burning.
There are other government programs that helps pay for long term care needs, you just need to better understand the requirements so you can qualify. You can get additional information about other government programs here: http://www.infolongtermcare.org/ltci-learning-center/what-is-long-term-care-insurance/government-long-term-care/
Or check the federal programs for LTC here:
https://www.ltcfeds.com/
For other information about medicaid program, check here:
http://longtermcare.gov/medicare-medicaid-more/medicaid/