How much is covered by Medicare?
Number of Days
|
Medicare Pays for Covered Services
|
You Pay for Covered Services |
1-20
|
Full Cost |
Nothing |
| 21-100 |
All but a daily co-pay* |
A daily co-pay |
| Beyond 100 |
nothing |
Full Cost |
- The co-payment is up to $114 per day in the year 2005. It can change each year. If you have a Medigap policy with the Original Medicare Plan, or are in a Medicare managed care plan or private fee-for-service plan, your costs may be different or you may have additional coverage.
Information about Skilled Care
Your physician has told you that skilled nursing and/or rehabilitative care is necessary following a hospital stay. But what exactly does that mean and how is it defined by Medicare? Here are some answers that will help answer those questions for you.
What is skilled care?
Skilled care, also called sub-acute care, is health care given when you need skilled nursing or rehabilitation staff to manage, observe and evaluate your care. Examples of skilled care include changing sterile dressing and providing physical therapy. A skilled nursing facility may be part of a nursing home or a hospital. Medicare covers certain skilled care services that are needed daily on a short-term basis of up to 100 days, as long as the patient continues to qualify.
Who can provide skilled care?
A physician must order skilled care, and certify that skilled care is necessary for a given time period. Skilled care requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and correctly. Skilled nursing and rehabilitation staff includes:
- Registered nurses;
- Licensed practical and vocational nurses;
- Physical and occupational therapists;
- Speech-language pathologists.
Why does a person need skilled care?
You receive skilled care to:
- Manage symptoms, including pain control
- Learn how to walk with a prosthesis
- Manage stroke recovery
- Improve range of motion, strength and stability after knee or hip replacement
- Regain strength and endurance after a debilitating illness.
Skilled care helps you get better, function more independently and/or learn how to take care of your health needs.
Medicare covers skilled care when you meet certain conditions.
Medicare will cover skilled care only if all of the following conditions are met:
- You must have Medicare Part A, or hospital insurance. If you are not sure if you have Part A, look on your red, white and blue Medicare card. It will show “Part A (Hospital Insurance)” on the lower left corner of the card. You can also find out if you have Part A by calling your local Social Security office, or call Social Security at 1-800-772-1213.
- You need to have days left in your benefit period available to use.
- You must have a qualifying hospital stay. That means an inpatient hospital stay of three consecutive nights or more, not including the day you leave the hospital.
- Your doctor has decided that you need daily skilled care. It must be given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you are in the skilled nursing facility in order to receive skilled rehabilitation services only, your care is still considered daily care even if these therapy services are offered just five or six days a week.
- You get these skilled services in a skilled nursing or sub-acute facility that has been certified by Medicare.
- You need these skilled services for a medical condition that:
a. Was treated during a qualifying three-day hospital stay, or
b. Started while you were getting Medicare-covered skilled care. An example of this would be if you were in the skilled nursing facility because you had a stroke and then you fell and sprained your wrist.
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What is custodial care? Custodial care, sometimes called intermediate or personal care, is care that helps you with usual daily activities like walking, eating or bathing. It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters. Custodial care is often given in a nursing facility. Generally speaking, skilled care is available only for a limited time after a hospitalization. Custodial care may be needed for a much longer period of time.
Medicare does not cover custodial care.
Information about your Medicare Benefit Period
How long will Medicare cover my skilled care?
Medicare uses a period of time called a benefit period to keep track of how many days of skilled nursing facility benefits you use and how many are still available. A benefit period begins on the day you start using skilled nursing facility benefits under Part A of Medicare. You can get up to 100 days of skilled nursing benefits in a benefit period. Once you use those 100 days, your current benefit period must end before you can renew your skilled nursing benefits.
Your benefit period ends when:
- You have not been in a skilled nursing facility or a hospital for at least 60 days in a row; or
- You remain in a skilled nursing facility, but have not received skilled care there for at least 60 days in a row.
There is no limit to the number of benefit periods you can have. Once a benefit period ends, though, you must have another three-day qualifying hospital stay and meet the Medicare requirements before you can get another 100 days of skilled nursing benefits.
If I stop getting skilled care in the skilled nursing facility or leave the facility, how does this affect Medicare skilled nursing coverage if I need more skilled care in a skilled nursing facility later on?
The answer depends on how many days have elapsed between the time you stopped receiving skilled care and the time you started receiving it again.
| If it has been less that 30 days |
- You do not need a new three-day hospital stay to qualify for coverage of additional skilled care.
- Since your break in skilled nursing facility care lasted for less than 60 days in a row, your current benefit period would continue. This means that the maximum coverage available would be the number of unused skilled nursing facility benefit days remaining in your current benefit period.
|
| If it has been at least 30 days but less that 60 days |
- Medicare will not cover additional skilled care unless you have a new three-day hospital stay. The new hospital stay need not be for the same condition that you were treated for during your previous stay.
- Since your break in skilled nursing facility care lasted for less than 60 days in a row, your current benefit period would continue. This means that the maximum coverage available would be the number of unused skilled care benefit days remaining in your current benefit period.
|
| If it has been 60 days or more |
- Medicare will not cover additional skilled nursing facility care unless you have a new three-day hospital stay. The new hospital stay need not be for the same condition that you were treated for during your previous stay.
- Since your break in skilled care lasted for at least 60 days in a row, this would end your current benefit period and renew your skilled nursing facility benefits. This means that another three-day hospital stay would begin a new benefit period with 100 days of skilled nursing facility benefits.
|
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Examples of Medicare Coverage
Seeing a few specific examples of how Medicare coverage works with benefit periods may be helpful to you.
In the three examples that follow, assume that the patients met all the qualifications for Medicare coverage of skilled nursing facility care, including the three-day qualifying hospital stay. They are admitted to a skilled nursing facility because they need skilled care, and are then discharged before their benefit period ends.
Example 1:
The patient has been out of the skilled nursing facility for less than 30 days.
Mrs. Perkins received 10 days of Medicare-covered skilled nursing facility care when she broke her leg. Her Medicare coverage ended when she stopped needing skilled care. She chose to go home rather than pay for custodial care. After 10 days, however, her doctor decided she needs more skilled care for her broken leg and she was readmitted to the skilled nursing facility. Medicare will cover this stay in a skilled nursing facility. She has 90 days of coverage left in her benefit period.
Example 2:
The patient has been out of the skilled nursing facility for at least 30 days but less than 60 days.
Mr. Jones received 20 days of Medicare-covered skilled nursing facility care when he had a stroke. His Medicare coverage ended when he stopped needing skilled care. He chose to stay in the skilled nursing facility and pay for two days of custodial care. He then went home. After 34 days, his doctor readmitted him to the hospital for four more days because of his stroke. He was then admitted to a skilled nursing facility because he needed skilled care. Even though Mr. Jones was out of the skilled nursing facility for more that 30 days, since he then had a qualifying hospital stay, Medicare will cover his stay in the skilled nursing facility stay. He has 80 days of coverage left in this benefit period.
Example 3:
The patient has been out of the skilled nursing facility for at least 60 days.
Mrs. Smith received 20 days of Medicare-covered skilled nursing facility care when she had back surgery. Her Medicare coverage ended when she no longer needed skilled care. She chose to go home rather than pay for custodial care. After 65 days, she was hospitalized for three days due to a fall. She was then admitted to a skilled nursing facility because she needed skilled care. Since she was out of the skilled nursing facility for more than 60 days, her benefit period ended. Her new three-day qualifying hospital stay starts a new benefit period. Medicare will cover up to 100 days of skilled nursing facility care in this new benefit period.
If I am in a skilled nursing facility but must be readmitted to the hospital, will the skilled nursing facility hold my bed for me?
There is no guarantee that a bed will be available for you at the same skilled nursing facility if you need more skilled care after your hospital stay. To guarantee reentry into the skilled care facility, you may pay the daily private rate to hold the bed.
What does Medicare cover when I qualify for skilled nursing facility care?
Medicare will cover all the following:
- Private room in an all-private room skilled nursing facility
- Semi-private room
- Meals
- Skilled nursing care
- Physical therapy if needed to meet your health goal
- Occupational therapy if needed to meet your health goal
- Speech-Language therapy if needed to meet your health goal
- Medical/social services
- Medications
- Medical supplies and equipment used in the facility
- Dietary counseling
What do I pay for skilled nursing facility care?
In the Original Medicare Plan, for each benefit period in the calendar year 2005, you pay the following.
| Number of Days |
Medicare Pays for Covered Services |
You Pay for Covered Services |
| 1-20 |
Full Costs |
Nothing |
| 21-100 |
All but $114 per day |
Up to $114 per day. This is your co-insurance amount. You must also pay all additional charges not covered by Medicare, such as telephone and laundry fees. |
| Beyond 100 |
Nothing |
Full Costs |
Payment Example 1:
Patient stays from 1 to 20 days in a skilled nursing facility.
Mr. Anderson is in the hospital for five days and is then admitted to a skilled nursing facility within 30 days of leaving the hospital. He is in the skilled nursing facility for 12 days. Mr. Anderson will not have to pay anything for this Medicare-covered skilled nursing facility care. He has 88 days of coverage left in this benefit period.
| Days in Hospital |
Days in Skilled Nursing Facility |
Amount Mr. Anderson Pays for Skilled Nursing Facility Care |
Days Left in Benefit Period |
| 5 |
12 |
$0 for covered services. (Your skilled nursing facility costs may be different if you are in a Medicare managed care plan or a Medicare Private Fee-for-Service plan. Check with your plan.) |
88 |
Payment Example 2:
Patient stays in the skilled nursing facility for 21 to 100 days.
Mrs. Baker is in the hospital for five days. She is then admitted to a skilled nursing facility within 30 days of leaving the hospital. She is in the skilled nursing facility for 30 days. Mrs. Baker will have to pay up to $1140.00 (the coinsurance for days 21-30, which can be up to $114 per day) for her Medicare-covered skilled nursing facility care. She has 70 days of coverage left in this benefit period.
| Days in Hospital |
Days in Skilled Nursing Facility |
Amount Mr. Anderson Pays for Skilled Nursing Facility Care |
Days Left in Benefit Period |
| 5 |
30 |
Up to $1140 for covered services, $114 per day for days 21-30. (Your skilled nursing facility costs may be different if you are in a Medicare managed care plan or a Medicare Private Fee-for-Service plan. Check with your plan.) |
70 |
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Are there any ways that I can get help paying for skilled care?
You may be eligible for help from the state.
If your income and assets are limited, you may be able to get help to pay for skilled care. If you qualify for both Medicare and Medicaid, most health care costs are covered. For more information, call the Kentucky Medical Assistance
Office at (502) 564-7372.
Long-term care insurance may cover some of the cost.
If you have long-term care insurance, check your policy or call the insurance company to find out if skilled or custodial care is covered. If you are shopping for long-term care insurance, find out which types of long-term care services the different policies cover. For more information about long-term care insurance, get a copy of Consumer Guide to Long Term Care Insurance 2003-2004 from the Kentucky Department of Insurance. You may call 1-800-595-6053 or request a copy in writing from the National Association of Insurance Commissioners, 120 West 12th Street, Suite 1100, Kansas City, MO 64105-1925.
When Your Medicare Coverage Ends
If you no longer qualify for Medicare coverage, you must be given a written “Notice of Medicare Non-Coverage.” The purpose of this notice is to let you know that the skilled nursing facility believes you no longer qualify for skilled nursing facility services paid by Medicare. If someone is acting on your behalf, the facility must notify them in writing. Medicare coverage ends the day after you get the notice.
The Medicare Notice of Medicare Non-Coverage must tell you:
- The date your Medicare coverage will end, and you must start to pay;
- Why your stay is not (or is no longer) covered;
- Your right to request that the skilled nursing facility send Medicare its opinion that your care no longer meets Medicare coverage requirements (Demand Bill).
- Where you, or someone acting on your behalf, should sign to show that you got the notice.
If you think you still need skilled nursing facility care, you have the right to have Medicare review the skilled nursing facility’s opinion in order to decide if you still qualify for Medicare coverage. However, if Medicare decides your care is no longer covered, you are responsible for the cost of the care you received while you were waiting for the decision.
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