The long-term care system has a language all its own. Below are answers to questions families often have.
What is Medicare?
MEDICARE – PART A
Skilled nursing facility (SNF) care Medicare Part A (Hospital Insurance) covers Skilled Nursing Care provided in a Skilled Nursing Facility (SNF) under certain conditions for a limited time.
Medicare-covered services include, but aren’t limited to:
Semi-private room (a room you share with other patients)
Skilled nursing care
Physical and occupational therapy*
Speech-language pathology services*
Medical social services
Medical supplies and equipment used in the facility
*Medicare covers these services if they’re needed to meet your health goal.
If you’re in a SNF but must be readmitted to the hospital, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.
Who is Eligible?
People with Medicare are covered if they meet all of these conditions:
- You have Part A and have days left in your benefit period.
- You have a qualifying hospital stay.
- Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you’re in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.
- You get these skilled services in a SNF that’s certified by Medicare.
- You need these skilled services for a medical condition that was either:
- A hospital-related medical condition.
- A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay.
Here are some common hospital situations that may affect your SNF coverage:
|Is my SNF stay covered ?
|You came to the Emergency Department
(ED) and were formally admitted to the
hospital with a doctor’s order as an
inpatient for 3 days. You were discharged
on the 4th day.
|YES. You met the 3-day inpatient hospital
stay requirement for a covered SNF stay.
|You came to the ED and spent one day
getting observation services. Then, you
were formally admitted to the hospital as an
inpatient for 2 more days.
|NO. Even though you spent 3 days in the
hospital, you were considered an outpatient
while getting ED and observation services.
These days don’t count toward the 3-day
inpatient hospital stay requirement.
Remember, any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.
If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (like if you get the flu), you may be able to continue to get Medicare coverage temporarily.
Your costs in Original Medicare
What You Pay:
- Days 1–20: $0 for each benefit period.
- Days 21–100: $157.50 coinsurance per day of each benefit period.
- Days 101 and beyond: YOU pay all costs.
- If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts. If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
- If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
What is Medicaid?
Medicaid is the largest program providing medical and health-related services, including nursing home care, to America’s poorest people. It covers approximately 36 million individuals, including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income maintenance payments. Within broad national guidelines that the federal government provides, each of the states:
- establishes its own eligibility standards;
- determines the type, amount, duration, and scope of services;
- sets the rate of payment for services; and
- administers its own Medicaid program.
What is the Social Security Disability Insurance program?
Social Security disability insurance pays monthly benefits to workers who are no longer able to work due to a severe illness or impairment that has lasted or is expected to result in death or to last at least 12 months. It is part of the Social Security program that pays benefits to the vast majority of elderly Americans. Benefits are based on the disabled worker’s past earnings and are paid to the disabled worker and his or her dependent family members. In order to qualify, a disabled worker must have worked in jobs covered by Social Security.
What is Supplemental Security Income (SSI)?
Supplemental Security Income (SSI) is a means-tested federal program that pays monthly benefits to low-income aged, blind and disabled individuals. For adults, it uses the same test of disability as the DI program. (For children, the standard is based on the ability to perform age-appropriate functions.) In order to qualify, the individual must have very low income and limited assets.