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Skilled nursing facility care – What are the requirements?

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Question: My mother is unable to walk without assistance by wheelchair or walker, cannot bathe on her own, has lower body assist, has dementia and fear of falling, and is on diapers, but the facility says she is highly functional. What are her chances of getting into a skilled nursing facility?

Skilled Nursing Facility Question

To receive Medicare-covered skilled nursing facility care, you have to have a qualifying 3-day hospital stay prior to being admitted to the facility.

Answer: In order for Medicare to cover skilled nursing facility care, you have to meet the following requirements:

 

  1. You have to have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. (Remember, the time you are being observed in a hospital before you are admitted doesn’t count toward the 3-day qualifying inpatient hospital stay.) You must enter the skilled nursing facility (SNF) within a short period of time (generally 30 days) of leaving the hospital.In addition:
  2. You have to have Medicare Part A (Hospital Insurance) and have days left in your benefit period. A benefit period begins on the day you start using hospital or SNF benefits under Part A of Medicare. You can get up to 100 days of SNF coverage in a benefit period. [Note: If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital (Part A)” on the lower left corner of the card. You can also find out if you have Part A if you call your local Social Security office, or call Social Security at 1-800-772-1213.]
  3. Your doctor has to order the services you need for SNF care, which require the skills of professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists, and are furnished by, or under the supervision of, these skilled personnel.
  4. You require the skilled care on a daily basis and the services must be ones that, as a practical matter, can only be provided in an SNF on an inpatient basis. If you are in an SNF for skilled rehabilitation services only, your care is considered daily care even if the therapy services are offered just 5 or 6 days a week.
  5. You need these skilled services for a medical condition that was treated during a qualifying 3-day hospital stay, or started while you were getting SNF care for a medical condition that was treated during a qualifying 3-day hospital stay. For example, if you are in an SNF because you broke your hip and then have a stroke, Medicare may cover rehabilitation services for the stroke, even if you no longer need rehabilitation for your hip.
  6. The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.
  7. You get these skilled services in an SNF that is certified by Medicare.

Question about Medigap and Medicare

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We recently received a question about Medigap and Medicare coverage.

Question: I have chronic inflammatory demyelinating polyneuropathy. I have to get IVIGs of gamunex-C. I have a nurse who comes in and gives me the IVIG which takes 6 hours. I am not house ridden, so is this covered by home health care?  It is very expensive and I am very lucky my supplemental health care in New York covers this after I meet the deductible.  I will be moving to North Carolina at the end of December and need to find out what Medicare covers and if there is a supplement that will help with the payment.

Answer: In order for Medicare to pay, you would have to be homebound. Patients are considered homebound if they meet these two criteria:

  1. Patients either need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or help from someone else in order to leave their home because of illness or injury, OR have a condition that makes leaving the home medically inadvisable.
  2. “There must exist a normal inability to leave home; and leaving home must require a considerable and taxing effort.”

You can check into Medigap, supplemental insurance through Medicare. Medigap is sold by private companies and can help pay some of the health care costs that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. Also look into Medicare’s prescription drug benefit (Part D).

For more information check out these sites:


Are Medicare Advantage Plans required to provide the same home health care benefit as Original Medicare?

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Medicare Advantage PlansQ: Are Medicare Advantage Plans required to provide the same home health care benefit as Original Medicare?

No. Although Medicare Advantage plans must follow Original Medicare’s rules for providing you care, they can impose different costs and restrictions (often expensive co-pays and high deductibles). Also, you may need to choose a home health agency or other healthcare provider that contracts with your Medicare Advantage plan and get your plan’s prior approval or a referral before receiving home health care. With Original Medicare, home health services, including skilled nursing and therapies, are fully covered and require no co-pays. Also, you can go to any doctor, hospital or other provider that accepts Medicare patients anywhere in the country.