Medicare and Skilled Nursing: What Is and Is Not Covered
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Last Updated: Mar 14, 2024For seniors who need intensive rehabilitation due to a serious health issue, Medicare will cover short-term stays in a skilled nursing facility / nursing home. That’s great for people recovering from surgeries or strokes, but Medicare won’t cover long-term care or permanent stays in a nursing home. That’s where Medicaid comes in.
To learn more about the differences between the two programs, how they handle care in skilled nursing facilities and nursing homes, and how they can work together, keep reading. To learn exactly how the two programs can work to your benefit in your specific circumstances, get in touch.
Comparing and Contrasting Medicare and Medicaid
Both of these government-funded insurance programs are incredibly complex, so there are many differences and similarities. In general, however, there are three critical differences between the two programs:
• Medicare is run by the federal government, so its rules are consistent across the country. Medicaid is run by state governments, so its rules vary by state.
• Medicare is for all Americans who are age 65 or older and/or disabled. Medicaid is for financially limited people of all ages.
• Medicare will not cover long-term care in nursing homes. Medicaid will cover long-term care in nursing homes.
As for similarities, both cover medical costs such as physician’s visits, hospital care, home health services, durable medical equipment for in-home care and prescription medication. Both can be used by seniors. Both are subsidized by tax dollars. And both are supervised by the Centers for Medicare and Medicaid Services (CMS).
Medicare Benefits
The Medicare program and its benefits are divided into four parts – A, B, C, D. Medicare Part A covers hospital care, including stays in skilled nursing facilities for up to 100 days. These stays are for short-term rehabilitation when intensive treatment from skilled nurses or rehab professionals is necessary. Medicare will cover 100% of the costs for the first 20 days in a skilled nursing facility, and then it will cover 80% of the costs for the next 80 days. After 100 total days in the facility, Medicare’s coverage will stop.
Examples of skilled nursing facility services include post-operative wound care, physical therapy, speech-language therapy, nutrition counseling, social services, medical equipment and care by registered nurses. Occupational therapy, which helps a patient become independent again, is also covered. An in-patient stay in a skilled nursing facility is common after major surgeries or a health event which impairs your independence.
In order for Medicare to cover skilled nursing services, beneficiaries must be enrolled in Part A and have already been in the hospital for at least a three-day stay. They may enter the skilled nursing facility within 30 days of leaving the hospital. In addition to the hospital stay requirement, the patient’s physician must order services that can only be provided at a skilled nursing facility as an inpatient.
The other parts of Medicare operate as follows:
• Medicare Part B covers medical expenses such as physician’s visits, outpatient hospital care, home health services, durable medical equipment for the home and some preventative services.
• Medicare Part C, also called Medicare Advantage, can be purchased through a private insurer and can include benefits from Part A and B, as well as prescription drug coverage and personalized benefits based on need.
• Medicare Part D covers prescription medication.
Medicaid Benefits
Nursing Home Medicaid will cover all the costs of residing in a nursing home for eligible seniors. This includes room and board, physician care, nursing services, medication, mental health care, physical therapy, 24/7 supervision and social activities. Some of the things Medicaid will not cover in nursing homes include a private room, specialized menu, comfort items or any care not considered medically necessary.
To be eligible for Nursing Home Medicaid, applicants need to meet financial and medical requirements. The financial criteria is an asset limit and an income limit. In most states in 2024, the individual asset limit for Nursing Home Medicaid eligibility is $2,000, and the individual income limit is $2,829/month. These limits can vary by state and marital status. The medical criteria in every state is needing a Nursing Facility Level of Care, but how that is defined and measured can vary by state.
Medicaid will also cover long-term care services and supports provided in the home through its Home and Community Based Services (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid. Medicare will not cover any type of long-term care, either in the home, nursing homes or any other settings.
Dual Eligibility: Having Medicare and Medicaid Simultaneously
It’s possible to enroll in Medicare and Medicaid at the same time. Seniors who do this are known as “dual eligible.” They can access all the benefits of both programs for more comprehensive coverage and lower out-of-pocket costs.
Medicare will cover most of the medical costs for dual eligible seniors, such as physician’s visits, in-home care and lab work. But if Medicare doesn’t cover the complete amount, Medicaid will pay for the difference, as long as the services are covered by the Medicaid plan. Dual eligible seniors also save money because Medicaid will cover the cost of their Medicare premiums.
How a Certified Medicaid Planner Can Help
If you or your loved one is in a skilled nursing facility but will need more care than Medicare covers, one of our Certified Medicaid Planners can provide invaluable assistance. You will be under the pressure of Medicare’s 100-day deadline, and trying to navigate the maze of Medicaid rules and submit a mistake-free application in that time will be next to impossible. Unless you have years of experience and in-depth knowledge of the system, which are planners do have.
They will know if you meet Medicaid’s financial requirements for Nursing Home Medicaid. If you don’t, they will also know if there are any strategies you can use to become eligible. It’s possible to reduce your assets or income to meet the limits without breaking any Medicaid rules, but trying to use these strategies without the help of a professional is not recommended.
Gathering all the financial paperwork that you will need to submit with the Medicaid application is the most time-consuming part of the process. If you don’t know what documents you need or where to look for them, it could take weeks of months. Certified Medicaid Planners will know the paperwork you need and where to find it. What’s more, they will know exactly how to present it with your application so it clearly illustrates your financial history for the Medicaid state officials reviewing the application.
Medicare coverage benefits millions of American seniors, but it doesn’t cover all of their needs. If you need long-term care, you’re going to need Medicaid, and our Certified Medicaid Planners can help you get it. Click here now to connect with one of them.
