If your loved one has had a recent medical event, such as a fall or a stroke, Medicare will help pay for their rehabilitation stay in a skilled nursing facility. Medicare (or an HMO replacement) is a Federally funded health insurance program for those over age 65 or disabled. Medicare has two parts – A & B.
Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. Most people don’t pay a Part A premium because they paid Medicare taxes while working. This is called "premium-free Part A."
Part B helps cover medically-necessary services like doctors' services, outpatient care, durable medical equipment, home health services, and other medical services. Part B also covers some preventive services. If you have Part B, you pay a Part B premium each month which is taken directly from your Social Security check. Most people will pay the standard premium amount of $148.50/month (2021) that is deducted from the recipient's social security check.
When dealing with Medicare in the long-term care planning context, we are frequently dealing with rehabilitation benefits. Here, Medicare covers skilled nursing and rehabilitative services that are medically necessary but only after a 3-day minimum hospital stay for a related illness or injury. To qualify for care in a skilled nursing facility, the elder's doctor must certify that he or she needs daily skilled care like intravenous injections or physical therapy. When this occurs, the costs for skilled nursing with Medicare are as follows:
Days 1–20: $0 for each day you are receiving rehab.
Days 21–100: $185.50 for each day you are receiving rehab.
Days 101 and beyond: all costs.
If the patient has a Medigap policy (i.e., a Medicare supplement) the policy may pay for the $185.50 per day (2021). The rules are generally similar, but not the same, if the patient has an HMO or PPO, generally known as a Part C plan. The nursing home (i.e., rehab center) social worker and/or business office can be helpful discussing Medicare benefits, although it can still be very confusing.
Will the Patient Get 100 Days Automatically?
No. When the patient is in skilled nursing getting care, it is exceedingly rare he or she can stay in rehabilitation for 100 days. Most people just do not need that much therapy. When the patient does not participate in rehabilitation, cannot participate to get stronger, or just finishes rehab, then Medicare will end.
Will Medicare pay for long-term care?
No. Medicare is health insurance, not does not pay for long-term care. Basically, Medicare will help with rehabilitation and other medical benefits but it does not provide long-term care, custodial services, assisted living benefits and more. This typically falls to the elder with Medicaid, VA or private paying for long-term costs.
What happens when Medicare Ends?
When Medicare ends, the patient generally has three choices:
- Go home
- Go to assisted living
- Stay in the nursing home under long-term care (i.e., not rehabilitation).
In any event, the family would likely want to consider asset protection and applying for Medicaid or VA benefits.
When Should We Apply for Medicaid?
Medicaid has a number of rules and it is highly likely that a good elder law attorney can protect assets and apply for benefits on the elder's behalf. Medicaid can help pay for the nursing home, importantly, and can help pay for in-home or assisted living care as well. To get Medicaid for assisted living on in-home care, there is likely a 60 day waitlist to navigate. There are legal ways to protect assets with good advice, including effective spend down planning. Importantly, you cannot gift the elder's assets away just before applying for Medicaid.
How can I learn more?
We have a short guide to questions to ask if your elder just went to the nursing home. No two situations are the same but we know that if your elder had a downturn in health and is just getting rehabilitation, then things are difficult. We also have a free book - Protect Your Nest Egg from a Florida Nursing Home that has a great deal of helpful information.
Also, we answer the difference between Medicaid and Medicare at this blog post.
Can Our Law Firm Help?
We may be able to help, even if your family is not a resident of Pinellas County, where we are. Medicaid is a state wide system, so we work with families across the state in protecting assets and applying for benefits.
We can help you and your family with:
- Discharge planning from the nursing home
- Resident care advocacy
- Care coordination
- Incapacity planning - powers of attorney and advance directives
- Asset protection planning