Medicare and skilled nursing care bills

LTCI Insider

Before 2013, Medicare paid for SNF care only if a patient was still getting better. Before 2013, Medicare paid for SNF care only if a patient was still getting better.

Margie Barrie, a veteran long-term care insurance (LTCI) agent, marketer and educator, has been writing articles about long-term care (LTC) planning and related issues for years.

See 2 ways to increase LTC product sales and 10 tips on buying leads.

Here she looks at how Medicare coverage can help with some types of LTC expenses, or LTC-like expenses, in some situations. 

Question: As part of my client presentation, I discuss Medicare and how you can’t depend on it to pay for long-term care expenses. My explanation includes that you must be getting better every day in order for Medicare to pay a nursing home bill. Is that still correct or have the rules changed?

Answer: The rules have changed! And I must admit it was rather embarrassing how I learned about it. I was meeting with Donna Blizman, a health agent who specializes in Medicare supplements and a past president of the Sarasota National Association of Health Underwriters (NAHU) chapter, to provide her with a LTC policy. When I went through my customary Medicare explanation, she informed me that it was no longer correct.

See also: 7 ways to count your clients' days

As Donna explained it, using the words that you no longer get benefits "after you have plateaued" or "are not getting better" is no longer accurate. Medicare has changed its criteria.

Now, in order for Medicare to pay, skilled care must be necessary to treat your medical condition, but, if you aren’t getting better, it doesn’t matter. You may have plateaued, but skilled nursing facility (SNF) care might be required to keep you from getting worse. If so, then you can still qualify for Medicare benefits in the nursing home.

For more details, I asked colleagues at America's Health Insurance Plans (AHIP) about the explanation they are using in their LTCI professional designation course, for the Long-Term Care Professional (LTCP) program.

Here's the description of the change in their updated textbook: 

Until recently, the requirement that skilled care be necessary to treat a medical condition was interpreted by Medicare to mean that a person’s condition had to be improving. For instance, if skilled care was required to help a person recover from a stroke, the medical necessity requirement was met; but if skilled care was needed by someone with an impairment that was not expected to improve, this requirement was not met.

But a 2013 court decision in response to a class-action suit has changed this. Now, even if a person is not expected to recover or improve, as long as the services of a health care professional are required as part of the treatment of her medical condition, she can continue to receive Medicare nursing home benefits. (Skilled care might be needed to maintain her condition or slow deterioration.)

Here are the rest of the facts about Medicare coverage of LTC in a nursing home – these have not changed.

Skilled nursing facility care provides high levels of medical and nursing care, 24-hour monitoring and intensive rehabilitation. It is intended to follow acute hospital care due to serious illness, injury or surgery — and usually only lasts a matter of days or weeks.

You must meet two requirements before Medicare will pay:

  1. Your stay in a skilled nursing facility must follow at least three consecutive days in the hospital, not counting the day of discharge. You must have been actually “admitted” to the hospital, not just held under observation, and your stay in the nursing facility must be within 30 days of being discharged from the hospital.
  2. Your doctor must certify that you require daily skilled nursing care or skilled rehabilitative services. Skilled nursing treatment requires trained professionals for giving injections, changing dressings, monitoring vital signs or administering medicines or treatments. Rehab services include those administered by professional therapists, such as physical, occupational or speech therapists. This daily care must be related to the condition for which you were hospitalized.

For the first 20 of 100 days, Medicare will pay for all covered costs. For the next 80 days, the patient is personally responsible for a daily co-payment and Medicare pays the rest of the covered costs. The co-pay is covered by the Medicare supplement.

See also: 20 ways to impress LTC planning prospects

Here’s how I now plan to handle this part of my client presentation: 

  • Briefly explain that Medicare does a great job of paying for hospital bills and doctor bills, and that the program was never intended to pay for long-term care expenses.

  • Note that Medicare will pay for SNF care when it follows a hospital stay of three days due to a serious illness, injury or surgery. This need for nursing home care usually only lasts a matter of days or weeks.

  • State that the bottom line is this: You cannot depend on Medicare to pay for long-term care. If it pays anything for long-term care, consider it a bonus.

That’s it! End of topic. And then on to a brief explanation of Medicaid.

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