Will Medicare And/Or Medicaid Cover My Loved One’s Skilled Nursing Care?

We understand that your loved one’s transition from the hospital or current residence to a skilled nursing facility can be a difficult time -- only complicated by often-confusing financial decisions required to ensure a fiscally-responsible stay. Financing any form of senior living is an understandably difficult topic to address and grasp.

Skilled nursing care involves specialty care provided by health care professionals with a particular area of expertise. It is typically required for seniors to help them recover to the best possible standard of living. Often times this care is the result of a recent procedure or illness and the senior and their family works with a doctor to determine the right option for them.

Determining whether the cost of your loved one’s skilled nursing stay can be covered by insurance programs like Medicare or Medicaid is one of the most important aspects of the decision -- as such, we’d like to offer some insight into that process.

Medicare and Medicaid are often used interchangeably, but the distinction between the two matters, particularly when you’re evaluating whether or not your loved ones’ skilled nursing care stay is covered.

Medicare is the largest health insurance program in the U.S. designed specifically for seniors. Enrollees receive benefits based on several eligibility criteria and requirements. Medicare offers Part A, Part B, Part C and Part D options. These options are not tiers, but rather separate forms of coverage that offer different benefits depending on a variety of factors. Below is a basic outline of each option and the benefits included.

  • Medicare Part A:
Hospitalization costs
  • Medicare Part B:
Physician services, lab and x-ray services, durable medical equipment, outpatient, and other services
  • Medicare Part C:
Medicare Advantage Plan (like an HMO or PPO) offered by private companies approved by Medicare
  • Medicare Part D:
Assists with the cost of prescription drugs

Medicaid is a federal health insurance program that provides benefits to nearly five million seniors, most of whom also receive Medicare benefits. Senior recipients, typically low-income seniors, often receive “extra help” from Medicaid that helps cover some of the costs of Medicare, such as premiums, co-payments, and other out-of-pocket expenses. The Medicaid website provides additional details about income limits for Medicaid programs for seniors.

“Will Medicare cover my senior parents’ skilled nursing care?”

Medicare coverage for a skilled nursing facility differs from coverage for a stay at a senior living community, even if the community offers standard long-term senior living services (i.e. independent living, assisted living, and/or memory care) as well as skilled nursing on one campus.

Jake Cox, Health Care Administrator at Marquette Senior Living in Indianapolis, Indiana, works with incoming residents, their families, and health care providers to make the entire skilled nursing care process -- from transition-in (often times from a hospital) to transition-out -- as seamless and comfortable as possible. As Cox explains, the decision for a senior to enter skilled nursing care after being discharged from the hospital is typically made by the resident, their family, the resident’s primary care physician and a health care expert at a skilled nursing facility or senior living community that offers skilled nursing care.

“We work closely with providers and doctors, alike. Every patient who is admitted to the hospital and discharged home is assigned a coordinator to help schedule a follow-up appointment with their primary care physician within two-weeks. At that point, if the patient requires additional care, the physician will suggest a higher level of care and contact Marquette for placement.”

Once a doctor has determined that skilled care provided by skilled nursing staff or therapy professional is necessary, the senior must also meet several eligibility requirements in order to receive Medicare coverage for their stay. These prerequisites include a qualifying hospital stay and Medicare Part A enrollment with days left in their benefit period. Also, the potential resident must require specialty care and/or therapy that can only be provided by a professional with a special area of focus (IV antibiotics, wound-care, tracheotomy-care, etc.). Even if the eligibility criteria are met, Medicare may only cover the skilled nursing stay for a specific period of time.

“Medicare requires that for coverage a patient must have had a three-night in-patient stay at a hospital before their skilled nursing facility (SNF) benefits can be utilized. Patients are eligible for 100 days in a skilled nursing facility, which includes medications, therapy, around-the-clock-care provided by nurses and aides, as well as equipment required for care (Wound-care supplies, oxygen, etc.),” Cox continued.

But, according to Cox, most residents don’t use all 100 days of available coverage.

“Resident therapy programs focus on achieving the prior level of function (that is -- how functional the resident was prior to admission to skilled nursing care), and the resident can be discharged when it is safe to return to their prior setting. The average length of stay of stay for a Medicare patient in skilled nursing at Marquette is 18 days.

As Cox explains, Medicare-covered skilled nursing residents are typically covered at 100% for 20 days and then 80% for each subsequent day until after day 100.

Skilled nursing care services covered by Original Medicare include a semi-private room, meals, medications, dietary counseling, skilled nursing and specific therapies (physical, occupational, speech, etc.) to help patients meet their goals. It is also important to remember that oftentimes doctors or health care providers may recommend services that Medicare doesn’t cover. If this happens the senior may be responsible for the payment of the services.

“If a resident cannot return home safely after a stay in our skilled nursing unit they have the option to transition to our long-term care unit and pay privately or use approved insurance, or our team of counselors will help coordinate a transfer to another community or skilled nursing facility that accepts long-term care coverage offered by Medicaid,” says Cox.

“Will Medicaid cover my loved one’s skilled nursing care?”

Like Medicare, eligible Medicaid recipients have to meet specific criteria for nursing facility care in their own state, yet the individual states’ requirements must also abide by federal law and regulations. This is true of anyone that receives Medicaid, including seniors who are dually eligible for both Medicare and Medicaid.

According to their official website, Medicaid provides coverage for skilled nursing care that allows each eligible recipient the opportunity to “attain or maintain the highest practicable physical, mental, and psychosocial well-being.” Medicaid covers a wide variety of services provided at a skilled nursing facility, such as skilled and specialty nursing, rehabilitative services, pharmaceutical services, medical social services, meals, and other care.

Although some senior living communities and skilled nursing facilities accept Medicaid benefits, it is not as commonly accepted as Medicare, so it is important to speak with an advisor at the hospital, community or facility prior to making a decision. In most cases, the hospital will assign each patient a case manager to act as a liaison between patients and their families and the admission teams at senior living communities and skilled nursing facilities.

“Where can I find Medicare-covered skilled nursing care for my loved one?”

If your senior loved one is currently in the hospital and a doctor or health care provider has determined that skilled nursing in a skilled nursing facility is required, their health care team should discuss the options available and will likely try to accommodate your loved one’s preferences. They should also assist you and your loved one in planning for the stay to ensure that your loved one’s options are clear, and you are equipped to make an educated decision, regardless of their enrollment concerning Medicare or Medicaid.

At Marquette Senior Living, a team of professionals led by an Admissions Liaison works closely with hospitals and health care providers daily to identify patients that may require skilled nursing care in a skilled nursing facility. Our admissions team will meet with the patient and their family to discuss needs, goals, room availability, pricing, insurance coverage, and services offered at Marquette. Our team of senior living professionals is equipped to help hospital patients, our residents, and their families make confident decisions that are health-focused and fiscally responsible. If someone you love needs physical, speech or occupational therapy or requires skilled nursing care, we can help. Fill out a contact form or call (317) 875-9700 today to discuss the options.