Medicare can be an invaluable resource to seniors, as it helps contribute to a large variety of benefits and services. Medicare is a federal health insurance program designed for those aged 65 and over, as well as those suffering from disabilities. It receives funding via the Supplementary Medical Insurance Trust Fund and the hospital Insurance Trust Fund.
While its provisions are extremely far reaching and robust, there are a lot of limitations and, as a result, a lot of misconceptions about what it does and does not cover, as well as the length of coverage. There are an especially high number of these misconceptions when it comes to skilled nursing facilities (SNFs) and long-term care facilities (LTCs).
One of the biggest misunderstandings of Medicare-based SNF coverage pertains to how many hours of care a resident receives. Medicare provides a set number of hours that are to be divided up accordingly throughout the week to maximize time spent with physical, occupational and speech therapists. Since daily care is required for Medicare coverage (more on that later), there can be a lot of down time. For example, 2-3 hours of therapy five or six days per week, and having the rest of the time to recuperate.
Another common misconception centers around the claim that Medicare will cover up to 100 days in a SNF. While technically true, there are a lot of rules and specifics that get overlooked. For example, Medicare covers the first 20 days at no cost, but beginning on the 21st day and through the 100th day, the individual must pay a daily coinsurance, which can reach up to $170.50 per day as of January 1, 2019. This coinsurance can sometimes take people by surprise despite it being covered in Medicare literature. Medicare SNF benefits cover 100 days at a time as long as Medicare SNF criteria (e.g., daily PT/OT required, skilled wound care, IVs, PEG tube, trach, etc.) is still met. A 60-day break is required to reset benefits. For example, if you or your loved one were to receive skilled nursing for 30 days, return home and you/they are not hospitalized for 60 full days, the benefit period re-sets. However, if you or your loved one returns to the hospital within those 60 days of leaving skilled nursing, benefits do not re-set and you will be entering the SNF with 30 days already used.
Additionally, Medicare will only cover SNF care if the following are true:
- A doctor must order care that requires the help of professionals like registered or licensed practical nurses, physical & occupational therapists or other similar caregivers
- You are required to receive skilled care on a daily basis (however, if a facility only provides care 5 or 6 days a week, Medicare will still acknowledge that as daily care)
- There is a detailed plan of care centered around progress towards objective and measurable goals. These goals and a prospective discharge date must be completed within 72 hours of admission
It is important to keep these factors in mind when planning or evaluating your or a loved one’s care at a skilled nursing facility.