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  Frequently Asked Questions

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Medigap

Will Medicare cover Nursing Home Stays?

That depends.  These are the requirements for Medicare to cover your skilled nursing facility (SNF) care.

  • You must have spent three days as an inpatient in the hospital before you go to the SNF (called a qualifying hospital stay)
  • You must enter the SNF within 30 days after leaving the hospital
  • You must require a certain amount of skilled nursing care or skilled therapy services
  • You must go to a Medicare-certified SNF

Medicare will only pay for your skilled nursing facility care if you've spent at least three days in the hospital as an inpatient during the 30 days before you're admitted to the facility.  The day you are admitted as an inpatient counts towards your qualifying stay, but the day you are discharged does not.  It's important to know that just because you spent the night in the hospital does not mean you wer admitted as an inpatient.  You may have been in the hospital under observation.  You are still considered an outpatient when you are under observation, and that time does not count toward your qualifying hospital stay.  You are only an inpatient when your docotr signs an order admitting you.  During any hospital stay, it's a good idea to ask your doctor if you have been admitted as an inpatient  or if you are under observation.

In addition to the qualifying hospital stay, you must need skilled care in order for Medicare to cover your skilled nursing facility care.  You must need skilled nursing care every day or skilled therapy sevices at least five days a week.  In your case, that skilled need is physical therapy.  Other types of skilled care include speech therapy and skilled nursing services like intravenous injections and catheter placement.  Speak with your doctor and the hospital discharge planner to figure out if your needs qualify you for Medicare-covered skilled nursing facility care.

If you meet all the criteria above, Medicare Part A will pay for upto 100 days in a skilled nursing facility per benefit period.  A benefit period starts the day you begin getting inpatient care (when you are officially admitted to the hospital) and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row.  In 2012, you pay a deductible of $1,156 at the start of each new benefit period.  You pay nothing for the first 20 days of skilled nursing facility care after you meed your Part A deductible.  For stays 21 through 100 days in the skilled nursing facility, you pay a copay of $144.50 per day.

The coverage rules and costs may be different if you're in a Medicare Advantage plan.


 

 

 

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Board on Aging & Long Term Care
1402 Pankratz Street, Suite 111
Madison, Wisconsin  53704-4001
FAX:  608 246 7001
BOALTC@Wisconsin.Gov