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How is Skilled Nursing Facility Care Covered by Medicare?

Written by David Maxwell

Medicare is a health insurance program for those who are age 65 and older, as well as for those who are younger than age 65 but have a qualifying disability. This program provides a wide range of both hospitalization and other health care related charges for those who are enrolled.

For example, Medicare Part A offers coverage for hospital care, hospice care, and some skilled nursing home / home health care benefits.

Medicare Part B offers coverage for medically necessary services, such as those that are necessary to diagnose or treat certain medical conditions, as well as preventive services that can help you in preventing conditions like the flu, and that may be able to detect certain conditions at an early stage so that they can be treated.

Medicare Part B also offers coverage for things like clinical research, ambulance services, durable medical equipment, mental health services, obtaining a second opinion before having surgery, and limited outpatient prescription medications.

Medicare Part A and Part B are referred to as “Original Medicare,” as these were the initial coverages that were available when Medicare was first established. Since that time, additional Medicare entities have been established. These include Medicare Part D – which offers coverage for prescription drug needs – and Medicare Part C, or Medicare Advantage, which offers an alternative way of obtaining your Medicare benefits.

Will You Need Skilled Nursing Home Care?

medicare supplementsWhile nobody likes to dwell on long-term care issues, it is a possibility that most everyone should plan for. That is because the odds of needing this care are high – and without the proper financial resources in place, even a minimal need for long-term care has the potential to deplete your retirement assets and income substantially.

According to LongTermCare.gov, someone who is turning age 65 today has an almost 70 percent chance of needing at least some type of long-term care services and support in their remaining years. And, while one-third of today’s 65-year-olds may not ever require long-term care, 20 percent of those who do will typically need it for at least five years or more.

For many people who are over the age of 65, care will be required for an average of three years. Based on statistics from the U.S. government, women typically need long-term care for longer than the average (3.7 years), while men, on average, require care for 2.2 years.

Given the high cost of a long-term care need, as well as the statistical probability of requiring at least some amount of care, those who plan for the payment of such care will often be in a much better financial position, regardless of their future needs.

How Much Does Nursing Home Care Cost?

Long-term care can be expensive. Each year, Genworth compiles a cost of care study that examines how much the average price tag is for skilled nursing home across the country, as well as assisted living facilities and home health care.

In this study, for 2016, Genworth found that the average monthly cost of a semi-private room in a skilled nursing facility was over $6,800. The cost of a private room weighed in ever higher, with an average of $7,698 – which equates to more than $92,000 per year.

Even the cost of a home health care need can be costly for those who just need a temporary or intermittent assistance with basic daily living activities like bathing and getting dressed. In the area of home health care, it was found by Genworth that the average monthly cost of both homemaker services and a home health aide were each more than $3,800.

There are some ways that you can help yourself to cover a long-term care need. Unfortunately, while Medicare is one way of taking care of short-term, recuperative needs, this source does not coverage as much for long-term care as many people think.

Does Medicare Pay For Skilled Nursing Home Care Costs?

There are some benefits offered for skilled nursing home care costs that is available through Medicare. These are offered through Medicare Part A (Hospitalization Coverage). If you qualify for these benefits, you may be able to obtain at least some amount of coverage through Medicare for the following services in a skilled nursing home facility:

  • Semi-private room (a room that you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy
  • Speech-language pathology services
  • Medical social services
  • Medications
  • Medical supplies and equipment that are used in the facility
  • Ambulance transportation (when other transportation poses a danger to health) to the nearest supplier of needed services that are not available at the skilled nursing facility
  • Dietary counseling

To obtain any of Medicare’s skilled nursing home facility coverage, it is essential that you first qualify.

This will require that you meet all of the following conditions:

  • You have Medicare Part A coverage, and you still have days remaining in your benefit period
  • You have a qualifying hospital stay – which entails “three Midnights”, or at least a stay of three nights
  • Your doctor has determined that you require daily skilled care that is provided by – or under the direct supervision of – skilled nursing or therapy staff. (It is important to note that, if you are in a skilled nursing home facility for skilled rehabilitation services only, your care will be considered as daily care, even if these therapy services are offered just five or six days per week, as long as you need and get the therapy services each day that they are offered).
  • You get the skilled care services that you require in a skilled nursing facility that is certified by Medicare
  • You need these skilled services for a medical condition that was either 1) A hospital-related medical condition, or 2) A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition

The care that Medicare covers cannot be just custodial in nature. This means that, if you just simply require assistance with basic daily living activities that are not the result of a specific illness or injury, then it is unlikely that Medicare will pay for the care that you need.

Likewise, covered care must be considered recuperative in nature. This means that the condition that is causing you the care need must be one that you can recover from (as versus an ongoing chronic condition).

Provided that you qualify for Medicare Part A skilled nursing home care benefits, you will still be required to pay the following amount(s) in 2017:

  • Days 1 through 20 – $0 for each benefit period
  • Days 21 through 100 – $164.50 coinsurance per day of each benefit period
  • Days 101 and beyond – You are responsible for paying all costs

So, even for those who qualify, if you remain in the skilled nursing home facility for at least 100 days, you would be required to pay more than $13,000 in out-of-pocket coinsurance.

And, if you are in the skilled nursing facility for more than 100 days, you would then be responsible for all costs going forward.

How Can You Help Yourself With Paying Medicare’s Skilled Nursing Home Coinsurance?

While Medicare can require a large amount of out-of-pocket costs, there are ways in which you can help yourself in covering these costs. One way is to purchase a long-term care insurance policy.

These policies will typically cover some or all of your services for skilled nursing home care, as well as for care at your home and / or in an assisted living facility.

There are several ways in which you can obtain long-term care insurance. One is to purchase a stand-alone long-term care insurance policy. Going this route will allow you to choose the various benefits and dollar amount that you anticipate you may need in the future.

Today, there are also many options regarding “combination” plans that will combine life insurance with a long-term care benefit, or an annuity that offers the ability to obtain funds for a long-term care need.

Likewise, many of the life insurance policies that are offered in the marketplace today will provide “living benefits.” This means that if you are diagnosed with a terminal illness and / or you require care in a skilled nursing home facility, you can access some (or all) of the funds in the policy’s death benefit for your current needs. (It is important to note that, if you take advantage of this option, the amount of money that you take from the policy’s death benefit will be deducted from the proceeds that are eventually paid out to the policy’s beneficiary).

In some cases, you may be eligible for Medicaid assistance in paying for your skilled nursing home expenses. Medicaid is a joint federal / state program what can help those who live limited financial resources in paying for their care.

Yet another option for helping you to pay for Medicare’s costly coinsurance in a skilled nursing home facility is to purchase a Medicare Supplement insurance policy.

Medicare Supplement insurance is designed for picking up various deductibles, coinsurance, and / or copayments that are not covered by Medicare itself. Because Medicare Supplement insurance often fills in Medicare’s coverage “gaps,” it is often referred to as Medigap.

Not all Medicare Supplement insurance policies will offer the same array of benefits. So, it is essential to ensure that, if you want to have coverage for the skilled nursing facility coinsurance, that you opt for a plan that offers this type of benefit.

Which Medicare Supplement Plans Provide Coverage For Nursing Home Costs?

Today, there are ten different Medicare Supplement insurance plans available. These plans are named after letters of the alphabet, with Plan A providing a basic set of “core” benefits, and the other plans providing these basic benefits, as well as additional coverage offerings.

With Medicare Supplement Plan A, the following set of core benefits are offered:

  • Medicare Part A coinsurance and hospital costs – up to an additional 365 days after Medicare benefits have been used up
  • Medicare Part B coinsurance or copayment
  • First three pints of blood each year
  • Medicare Part A hospice care coinsurance or copayment

There are several Medigap plans that will pick up the cost of Medicare’s skilled nursing facility care coinsurance. These include Medicare Supplement Plan C, Plan D, Plan F, Plan G, Plan M, and Plan N.

Medigap Plan G will pick up 50 percent of skilled nursing facility care coinsurance, and Plan L will pick up 75 percent of these coinsurance charges.

How To Get The Best Rates On A Medicare Supplement Insurance Plan

Before purchasing a Medicare Supplement insurance policy, it will be important that you shop around and compare the premium prices that are being charged. This is because, while the benefits that are offered by all plans of a certain letter must be identical, each insurance company that offers these plans can charge a different rate.

In finding the best rates for Medicare Supplement coverage, it is typically recommended that you work with an independent insurance broker or agency that has access to many insurance carriers. This will allow you to directly shop and compare, and from there, you can determine which will be the best for you.

If you are in need of Medicare Supplement insurance coverage, we can help. We work with many of the top Medigap insurers in the market place, and we can assist you with obtaining all of the details that you need. In order to do so, just simply fill out the form on this page.

Should you still have any questions regarding Medicare and / or Medicare Supplement insurance, please feel free to call us directly, toll-free, at 864-332-4209. Our experts can walk you through your Medigap options so that you obtain the coverage that is best for you. So, contact us today – we’re here to help.

Sources: www.Medicare.gov
About Growth 360, LLC
About Growth 360, LLC

We work with individuals across the nation to secure the best Medicare Supplement rates.

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