Medicare defines Skilled Nursing as “nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. It’s health care given when you need skilled nursing or skilled therapy to treat, manage and observe your condition, and evaluate your care.”
Medicare covers a slew of services from the hospital to the home. Unfortunately, navigating the ins and outs of Medicare, or any insurance, can become distressing and often unclear.
In an attempt to simplify the insurance jargon, we have broken down the general requirements and qualifications for Medicare to cover your skilled nursing care.
Medicare is separated into many policies. Depending on which is more suitable for your finances and needs, you can choose between Original Medicare or Medicare Advantage. Under Original Medicare, Part A is automatically your policy when you enroll. Medicare Part A is your hospital insurance. This helps to cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health.
You will be provided the choice to opt-in or opt-out of Medicare Part B. If you decide to opt-out because it is not needed at the time, you may still enroll with it later on.
Medicare Part B is your medical insurance and helps cover doctor appointments, outpatient care, home health care, and durable medical equipment.
Part D is drug insurance that you can purchase, covering prescription medications, vaccines, and other necessary injections. Original Medicare doesn’t cover everything; there are some out-of-pocket costs and your coinsurance (usually around 20%). You can receive help covering these additional fees by purchasing supplemental coverage, like Medigap.
Medicare Advantage – or Medicare Part C – takes a different approach. Medicare Advantage is a plan offered by some private insurance companies. Part C is an alternative method that “bundles” the benefits of Part A and Part B and generally includes Part D in most plans.
Monthly premiums vary between companies and policy choices. Typically, there are more benefits, for example, dental, vision, and hearing.
Medicare Requirements For Inpatient Skilled Nursing
An inevitable part of the human body is our ability to heal and bounce back from surgery or an accident or illness decreases as we age.
The recovery period typically involves a significant amount of assistance and additional care for many seniors. Monitoring vitals and the rise of complications becomes essential to the person’s wellbeing. Because of this, many doctors will recommend transferring to an inpatient skilled nursing facility before returning home.
Medicare covers inpatient skilled nursing care considerably more broadly than it does for in-home care. Inpatient care falls under Medicare Part A, as explained further below.
Inpatient Skilled Nursing Facilities (SNF): Medicare Part A
When discussing inpatient care through Medicare coverage, there are five general requirements. The first two requirements work together:
- you are enrolled in Medicare Part A with days in your benefit period to use
- you have a qualifying hospital stay
It sounds simple, but what does it mean?
Your benefit period is how Medicare keeps track of your acquired hospital and skilled nursing facility services. The benefit period ends if you have not received any hospital or SNF care for 60 consecutive days. A new one will start if you need to go to the hospital after your last benefit period. It may not seem like an impact, but the catch is that you are required to pay the inpatient hospital deductible for each benefit period that starts.
Second, a qualifying hospital stay will have the most impact on whether or not Medicare will cover services in an SNF. Your qualifying hospital stay is the time you spend as an inpatient receiving care in a hospital. You must be an inpatient – observation is excluded – for a minimum of three days. Any outpatient care and your admission and discharge dates do not count towards the three days.
3. “your doctor must certify that you need daily skilled care which, as a practical matter, you can only get as a skilled nursing facility inpatient.”
4. any skilled nursing care and services must be provided by an SNF certified by Medicare, such as Bridge Care Suites.
5. the last requirement broadly covers the reasons why you need skilled assistance. For example, “a hospital-related medical condition treated during your three-day qualifying stay; a condition that started while receiving treatment while at an SNF.”
Medicare Requirements for In-Home and Outpatient Skilled Nursing
There are many reasons people choose to recover strictly within their homes or use outpatient care.
The security of being in your own home instead of a hospital-like setting is beneficial for some. As a result of anxiety or discomfort of being in an unfamiliar place, stress causes an imbalance in the body. Reducing stressors and feeling comfortable and safe allows the body to direct energy towards healing.
In-Home Skilled Nursing Care And Outpatient Skilled Nursing Care: Medicare Part B
Medicare Part B is dedicated to medically necessary doctor services, outpatient care, home health services, durable medical equipment, and other medical services that do not take place as an inpatient.
The requirements for Medicare coverage on in-home skilled nursing care are more limiting. The three broad requirements are:
- you must be under the care of a doctor
- a doctor must verify your need for skilled nursing services at home
- your doctor must certify that you are homebound
Starting with number one, let’s dig deeper. To be under a doctor’s care essentially states that the services you are requesting are part of an established treatment plan created and regularly reviewed by your doctor.
The second requirement is more detailed and where many limitations are found. Part B will only cover skilled nursing in intermittent time frames. This prohibits coverage for daily care. The services you need must be explicit to the condition being treated. Eligibility requirements boil down to a handful of specifics, such as the condition being treated is expected to show significant improvement within a given time frame. The skilled caregiver(s) you hire must be employed through a Medicare-approved agency.
A homebound person is considered to “have trouble leaving their home without help from an assistive device or another individual; your condition is at risk of worsening if they leave their home; and, they normally do not leave home because of the difficulty.”
Even homebound, skilled care services must adhere to the guidelines. If you need more than intermittent skilled nursing care, you will not be eligible for Medicare’s benefits for home health.
Contact Bridge Care Suites
Whether it’s Medicare, private insurance, or some combination, the continuously shifting regulations, policies, and eligibility is not easy to keep up with.
As a Medicare-certified short-term skilled nursing rehabilitation facility, Bridge Care Suites can help you uncover what type of coverage you have and if there will be any out-of-pocket costs to plan for. Additionally, we accept several other insurances, all of which can be clarified in-depth for you, with a simple call to Bridge Care Suits Guest Billing Coordinator (217-787-0000) or by filling out the online form.