Families often rely on Medicare, the Federal health insurance program that offers health coverage, to cover nursing home care for their loved ones, but what happens when Medicare stops paying for nursing home care? While Medicare offers health coverage, understanding Medicare coverage for nursing home care and the limitations on the Medicare part of coverage for nursing home care is key to planning for continued care in nursing homes.
When Medicare coverage for nursing home care ends, families must explore alternative options to cover nursing home care. Finding alternatives after Medicare stops paying for skilled nursing facility care can be an intimidating task, especially when trying to ensure their loved one receives the specialized care they need.
Elder law attorneys at Curcio & Casciato in Chicago, IL, explain what to do when Medicare stops paying for nursing home residents’ skilled nursing care. Our Chicago nursing home abuse lawyer team is experienced at guiding families through the challenging process of exploring options such as Medicaid services, veterans benefits, and long-term care insurance to cover nursing home expenses when Medicare coverage ends.
How Many Days Does Medicare Pay for a Skilled Nursing Facility?
A skilled nursing facility (SNF) provides skilled nursing care. Skilled nursing care in skilled nursing facilities means that residents are offered skilled care and rehabilitation services by registered nurses.
Skilled nursing facilities differ from standard nursing homes, as standard nursing homes offer custodial care for daily living activities. Skilled nursing facilities are designed for individuals requiring care and therapy for a hospital-related medical condition after a qualifying inpatient hospital stay.
Medicare covers skilled nursing facility care for a limited time, up to 100 days, as part of its Medicare benefits. Medicare coverage is intended to support recovery and transition back home. According to Medicare.gov, during this time, you’ll pay the following while Medicare generally overs the rest:
- $0 for days 1-20 (note: the Medicare Advantage Plan may charge copayments during this period)
- $204 per day for days 21-100
- All costs after day 100
To qualify, patients must have a qualifying hospital stay of at least three consecutive days and require skilled nursing care or rehab services. Medicare pays for a portion of the costs during the covered period.
What Qualifies as Skilled Nursing Care for Medicare Coverage?
Medicare Part A covers skilled nursing facility care on a short-term basis if specific eligibility criteria are met. First, you must have Medicare Part A with available days in your benefit period. Additionally, you must have had a qualifying inpatient hospital stay and enter the skilled nursing facility within a short time (generally 30 days) after leaving your inpatient hospital stay. Your doctor or another healthcare provider must determine that you require daily skilled care, such as intravenous fluids or medications or physical or speech therapy, which must be administered by or under the supervision of skilled nursing care or therapy staff in a Medicare-certified skilled nursing facility.
The skilled nursing care you receive must address an ongoing hospital-related medical condition that was treated during your qualifying hospital stay, even if it wasn’t the primary reason for your hospital admission or a new condition that developed while receiving skilled nursing care. These services are intended to improve or maintain your current hospital-related medical condition or developed condition. Examples of skilled services include wound care, injections, and rehabilitative services like physical, speech, and occupational therapies.
Your qualifying hospital stay or inpatient hospital care must meet specific eligibility criteria to qualify for Medicare coverage for a skilled nursing facility stay. What’s a qualifying inpatient hospital stay?
This means you must have been admitted as an inpatient for at least three consecutive days, excluding the day of discharge. Outpatient time before admission doesn’t count toward this inpatient hospital care requirement. Some Medicare coverage plans, like the Medicare Advantage Plan, may waive the three-day minimum stay requirement.
What Does Medicare Cover in a Skilled Nursing Facility?
Medicare covers skilled nursing care in a skilled nursing facility to support recovery and transition back home. The following services are typically covered:
- Semi-private room accommodations
- Meals
- Skilled nursing care
- Physical, occupational, and speech therapy
- Medical social services
- Medications
- Medical equipment and medical supplies
- Ambulance transportation (when necessary)
- Dietary counseling
Medicaid services are not limited to this list. By covering these essential services, Medicare generally helps patients receive the care they need in a skilled nursing facility.
Will I Be Kicked Out of a Nursing Home if Medicare Stops Paying for Skilled Nursing Services?
If Medicare Part A (Hospital Insurance) stops paying for skilled nursing care, you won’t necessarily be kicked out of the nursing home. However, the nursing home may initiate a discharge process if they can no longer provide the necessary care without Medicare coverage. In this situation, nursing homes must provide written notice 30 days prior to discharge; offer assistance in finding alternative care; and, ensure a safe and orderly discharge.
You or your representative can appeal the discharge decision if you feel it’s inappropriate. Additionally, you may be eligible for other payment options, such as Medicaid, private insurance, or veterans’ benefits, to continue receiving skilled nursing care in a nursing home. Understanding your Medicare coverage and available alternatives can help you plan for continued care.
Limitations of Medicare Coverage
Medicare coverage has limitations, including:
Time limits: Medicare covers skilled nursing care for up to 100 days per benefit period.
Eligibility: Medicare only covers skilled nursing care for patients who require daily skilled care and have a qualifying hospital stay.
Coverage gaps: Original Medicare doesn’t cover everything, such as:
- Long-term care (custodial care)
- Most dental care
- Eye exams (for prescription glasses)
- Dentures
- Most cosmetic surgery
- Massage therapy
- Routine physical exams
- Hearing aids and exams to fit them
- Concierge care
- Covered items or services from an opt-out doctor or provider (except in emergencies)
Coinsurance: Patients may be responsible for daily copays (up to $204 in 2024) for skilled nursing care.
Network restrictions: Medicare coverage may be limited to specific providers or facilities.
However, you may be able to get additional coverage through other health insurance that works with Medicare. Medicare Advantage Plans (Part C), Medicare Cost Plans, or Programs of All-inclusive Care for the Elderly (PACE) plans may cover extra benefits like vision, hearing, and dental services.
What Happens When Medicare Stops Paying for Nursing Home Care: Medicaid Coverage
When Medicare stops paying for nursing home care, many individuals and families turn to Medicaid coverage as a possible solution. Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families, including those in need of long-term care services like nursing home care.
While Medicare and Medicaid are both government-funded programs, they serve distinct purposes and have different coverage options. Understanding how Medicaid works and its role in providing coverage for nursing home care can help individuals and families plan for continued skilled nursing care and support.
Medicaid Eligibility Criteria
To determine Medicaid eligibility as a senior in Illinois, you must meet specific requirements. You must have limited income ($2,742/month) and resources ($2,000) and require a Nursing Home Level of Care. You must also be a U.S. citizen or qualified non-citizen and a resident of Illinois.
Exempt assets include your primary residence (up to $750,000 in equity), one vehicle, and personal effects. If you exceed income/resource limits, you may still qualify through a “spend-down” process. A medical evaluation determines the need for the nursing home level of care. Consult an elder law attorney from Curcio & Casciato for up-to-date information and personalized guidance.
What Happens When Medicare Stops Paying for Nursing Home Care: Alternative Options to Pay for Nursing Home
When Medicare coverage ends, alternative options can provide financial assistance for nursing home care. Personal savings, long-term care insurance, and life insurance can help cover costs. Veterans benefits may also be available for eligible individuals.
Financial resources can be stretched thin when paying for skilled nursing facility care. Exploring alternative payment options can provide relief.
Financial planning services can help individuals and families prepare for nursing home care costs. By understanding available options, you can make informed decisions about your care and financial future.
Long-Term Care Insurance
Long-Term Care Insurance provides financial support when Medicare coverage ends. It helps pay for nursing home care, assisted living, and home care services, maintaining control over care choices.
Policies cover services such as skilled nursing care, rehabilitative therapy, daily living assistance, and home care. They can be tailored to fit needs and budgets.
Investing in Long-Term Care Insurance brings peace of mind and financial security, protecting assets and guaranteeing necessary care.
Personal Savings
When Medicare coverage stops paying for nursing home care, personal savings can be used to cover costs. This includes funds from bank accounts, investments, or other sources.
Nursing homes are expensive, with costs ranging from $5,000 to $10,000 per month. Personal savings can bridge the financial gap.
Using personal savings maintains independence and choice of care, reducing the burden on family members. It’s part of a comprehensive plan for long-term care.
Life Insurance Policies
Life insurance policies can be used to pay for nursing home care when Medicare stops covering costs. Some policies allow for accelerated benefits, providing a lump sum to cover expenses.
Unlike paying monthly premiums for long-term care insurance, life insurance policies can provide a death benefit and living benefits. This flexibility can help cover nursing home or skilled nursing facility costs.
Converting a life insurance policy to pay for nursing home care can be a viable option, providing financial support when needed.
Veterans’ Benefits
Veterans benefits offer health coverage for eligible veterans, surviving spouses, and dependent parents. When Medicare stops paying, these benefits can help cover medical expenses, including skilled nursing services.
Eligible individuals can receive financial assistance for nursing home care, including skilled nursing facilities, adult day health care, and home health care. Services covered under veteran benefits may include physical therapy, occupational therapy, speech therapy, and assistance with daily living activities.
Veterans benefits can also cover respite care, hospice care, and palliative care, providing a range of support services for those in need. By making the most of these benefits, eligible individuals can access quality care and manage medical expenses, including skilled nursing services in a nursing home or other settings.
What Happens When Medicare Stops Paying for Nursing Home Care: Alternative Personal Care Options
When Medicare stops paying for nursing home care, individuals and families face a critical decision. Fortunately, alternative personal care options are available, offering flexibility and support. Assisted living facilities, home health therapies, and family caregivers can provide essential care and assistance.
These alternatives can provide tailored support, such as help with daily living activities, medication management, and rehabilitation services. By considering these options, families can find the right fit for their loved one’s specific needs and preferences, ensuring a more personalized approach to care.
Assisted Living Facilities
Assisted living communities offer a supportive environment for individuals who require personal care assistance. Registered nurses (RNs) and/or licensed practical nurses (LPNs), along with certified nursing assistants (CNAs), provide help with daily living activities, such as bathing, dressing, and medication management. This setting allows residents to maintain independence while receiving the care they need.
In an assisted living community, residents can enjoy social activities, meals, and transportation while receiving tailored support. This alternative care option provides a more home-like atmosphere, allowing individuals to thrive in a setting that fosters dignity and autonomy. With assisted living, individuals can receive the care they need without the skilled medical care provided in a nursing home.
Home Health Therapies
Home health therapies provide medical care in the comfort of one’s own home. Registered nurses, therapists, certified nursing assistants, and other medical staff offer personalized support, including wound care, physical therapy, and medication management. This alternative care option allows individuals to maintain independence while receiving necessary medical attention.
Home health therapies adapt to individual needs, providing flexible scheduling and customized care plans. With the support of registered nurses and certified nursing assistants, individuals can recover, rehabilitate, or manage chronic conditions in a familiar setting, delaying or avoiding the need for institutional skilled nursing care services.
Family Caregivers
When Medicare stops covering nursing home costs, family caregivers can provide emotional support and hands-on care. By assuming caregiving responsibilities, families can help their loved ones avoid the financial burden of nursing home costs. This care option allows individuals to receive personalized attention and support in a familiar setting.
Family caregivers can assist with daily living activities, manage medications, and coordinate medical appointments. While this care option requires a significant time commitment, it can be a cost-effective alternative to nursing home care. Additionally, family caregivers can provide companionship and emotional support, which can be invaluable for their loved one’s well-being.
How to Choose a Safe Nursing Home in Illinois
To choose a safe nursing home in Illinois, research facilities through the Illinois Department of Health and Human Services and read reviews on the Illinois Department of Public Health’s Nursing Home Finder. Knowing how to choose a nursing home that meets your loved one’s needs and understanding what things nursing homes are not allowed to do in Illinois is key. Consider factors like staffing levels, cleanliness, and resident satisfaction.
If you need to remove a patient from a nursing home, document incidents and report them to the facility and state authorities. Then, research alternative facilities and schedule tours. Resources like the Illinois Nursing Home Ombudsman Program can guide you. When transferring, coordinate with the new facility and healthcare providers. Remember to update records and notify relevant parties.
How to Report Nursing Home Abuse in Illinois
To report nursing home abuse in Illinois, contact the Illinois Department of Public Health’s Nursing Home Complaint Hotline at 1-800-252-4343. You can also file a complaint online or mail a written report to the department. Provide detailed information about the abuse, including dates, times, and witnesses. Elder law attorneys at Curcio & Casciato can offer guidance and support throughout the process.
Nursing home residents and their families can also report abuse to the Illinois Long-Term Care Ombudsman Program or local law enforcement. Reporting abuse helps protect vulnerable individuals and ensures accountability. If you suspect abuse, don’t hesitate to report nursing home abuse in Illinois and advocate for the well-being of your loved one.
How a Chicago Elder Law Attorney Can Help When Medicare Coverage Stops
When Medicare stops paying for nursing home care, families face difficult decisions. Nursing home costs can be overwhelming, and coverage options may be limited. A Chicago elder abuse attorney can help families explore alternative care options and protect their loved one’s rights.
A Chicago elder law attorney can guide families through the process of finding affordable care, understanding coverage options, and advocating for their loved ones. If abuse or neglect is suspected, a Chicago elder abuse attorney can help take action.
For personalized guidance, contact contact Curcio & Casciato. Our experienced attorneys can help you understand your options and make informed decisions about your loved one’s care. Don’t face these challenges alone – let us support you—call (312) 321-1111 to schedule an appointment today.
