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Health Insurance Basics

Does Medicare Cover Nursing Home Care?

July 28, 2017

If you rely on Medicare for all or most of your health coverage needs, will Medicare pay the expenses associated with nursing home care? The short answer is, it depends on whether you need long-term care or skilled nursing services.

According to Medicare.gov, Medicare Part A (hospital insurance) covers medically necessary care in a skilled nursing facility (SNF) following an acute illness or injury for which you were admitted to a hospital. But if you are in a nursing home only because you need help with daily activities like dressing and bathing, Medicare will not cover your stay.

Skilled Nursing Versus Long-term Care

Medicare coverage is provided if all of these conditions are met:

  • You have a qualifying hospital stay of at least three days as an inpatient. This doesn’t include being admitted to the hospital for observation
  • Your doctor has determined that you need daily skilled care given by skilled nursing or therapy staff.
  • You receive these skilled services in a SNF that's certified by Medicare.
How Many SNF Days Will Medicare Cover?

You may be used to thinking of a benefit period as either a calendar year or a contract year depending on your health plan, but Medicare uses a different definition. Medicare will pay for up to 100 SNF days per rolling benefit period.

According to Medicare rules, your benefit period starts the first day you spend as an inpatient at a hospital. That benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row. There is no limit to the number of benefit periods. Here is a basic SNF guideline on coverage by days:

  • For days 1-20, Medicare will pay all covered charges associated with your stay.
  • For days 21-100, you will pay coinsurance of $164.500 per day*. If you have supplemental insurance, it may cover all or part of your coinsurance.
  • If you reach day 101, you will pay 100 percent. Neither Medicare nor supplemental insurance plans will pay for days beyond 100.
  • If you are able to start a new benefit period by not receiving inpatient care for 60 days, Medicare will start over paying covered charges as above.
How Do I Know How Many Medicare Days I Have Left?

Medicare keeps track of your days for each benefit period. If you are covered by Medicare Part A and are a hospital inpatient, hospital staff will inform Medicare. Then, when you are ready to be discharged from the hospital to the SNF, someone from the SNF will contact Medicare to find out how many covered days you have available. That employee will also contact your supplemental health plan, if applicable, to coordinate benefits. Medicare will count all calendar days you spend at the SNF except the day you arrive and the day you leave.

What Happens If I Don’t Use All My SNF Days at Once?

You do not need to use all your Medicare days at once. If you become acutely ill while receiving SNF care and need to be admitted to a hospital, Medicare will not count the days of that hospital stay as part of your 100 days.

If you are discharged from that hospital to return to a SNF, Medicare will resume counting days from when you left the SNF to be admitted.

If you are discharged home from the hospital but return to the SNF within 30 days of hospital discharge, Medicare will resume counting days left in the same benefit period.
*As of 2017

Y0114_17_32136_I  07/28/2017
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A CONSUMER’S GUIDE TO HEALTH INSURANCE FOR PEOPLE ELIGIBLE FOR MEDICARE MAY BE OBTAINED FROM YOUR LOCAL SOCIAL SECURITY OFFICE OR FROM THIS INSURER

Empire BlueCross BlueShield is an HMO plan with a Medicare contract. Enrollment in Empire BlueCross BlueShield depends on contract renewal. Services provided by Empire HealthChoice HMO, Inc. licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Services provided by Empire HealthChoice Assurance, Inc., licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

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