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Home > Administrator > Office of Ombudsman > Tip Sheets > Nursing Home Care Tips

Tip Sheets

Will Medicare pay my nursing home bill?

MEDICARE SKILLED NURSING FACILITY BENEFITS

Medicare helps pay for services in a Medicare participating nursing home following a hospitalization when your condition requires daily skilled nursing or rehabilitation services which can only be provided in a skilled nursing home.

If you are not sure whether a nursing home participates in Medicare, ask the nursing home social worker or billing staff.

Medicare will pay when all five of the following conditions are met:

(If you have an HMO Risk contract, check with your contract representative)

1. Your medical condition meets skilled nursing or skilled rehabilitation services level. These are services that can only be provided by or under the direct supervision of licensed nursing or rehabilitation personnel (such as a registered nurse and physical therapist) in a skilled nursing facility;

2. You are hospitalized for at least three (3) consecutive nights, not counting day of discharge, prior to moving into the skilled nursing facility;

3. You were admitted to a skilled facility within thirty (30) days after discharge from a hospital;

4. Your care in the skilled nursing facility is for a condition that was treated in the hospital. Medicare may also pay for other conditions that arise during your nursing home stay; AND

5. A medical professional certifies that you need skilled nursing or skilled rehabilitative services on a daily basis

Skilled nursing means care that can only be performed by, or under the supervision of licensed nursing staff. Skilled rehabilitation services are therapies performed by, or under the supervision of a licensed therapist. A physician must order both.

Examples of skilled nursing or rehabilitation services:

1. Skilled management, observation and evaluation when your condition is so complex that you are likely to develop serious complications without the involvement of a licensed nurse to manage and plan your care.

2. Assessment of your rehabilitation needs includes tests and measurements of range of motion, strength, balance, coordination, endurance, etc.

3. Intravenous or intramuscular injections and intravenous feeding.

4. Tracheotomy aspiration

5. Application of dressings involving prescription medications and aseptic techniques. Care of extensive decubitus ulcers or other widespread skin disorder.

6. Initial phases of administration of medical gases.

7. Teaching and training activities.

MEDICARE DOES NOT PAY FOR NURSING HOME SERVICES WHEN:

• You need skilled nursing or rehabilitation services only occasionally or you can get skilled services outside of a nursing home setting or

• You need custodial care only. Custodial care is help with activities of daily living.

Examples of custodial care (also called supportive services):

1. Administration of routine oral medications, eye drops, ointments.

2. General maintenance care of colostomy or ileostomy.

3. Routine services in connection with indwelling bladder catheters.

4. Changes of dressings of non-infected postoperative or chronic conditions.

5. Preventive and palliative skin care, including bathing.

6. General methods of treating incontinence.

7. Assistance in dressing, eating and going to the toilet.

8. Periodic turning and positioning in bed.

9. Performance of repetitious exercises that do not require skilled rehabilitation personnel for their performance.

NURSING HOME SERVICES COVERED BY MEDICARE

• Semi-private room (2 to 4 beds)

• Meals, including special diets

• Regular nursing services

• Rehabilitation services (physical, occupational and speech therapy)

• Drugs furnished by the facility

• Blood transfusions

• Medical supplies

• Use of wheelchair, walker, etc.

• X-ray and laboratory services

MEDICARE PAYMENT FOR NURSING HOME SERVICES

• Medicare pays for the entire daily cost for the 1^st through the 20^th day.

• From the 21^st through the 100^th day, Medicare pays the daily cost except for a copayment that you must pay. For the year 2003, the copayment is $105.00. The amount of the copayment increases each year.

• Medicare coverage ends at midnight of the 100^th day.

The publication Medicare Coverage of Skilled Nursing Facility Care from Medicare gives a detailed explanation of coverage. To obtain this booklet, you may call Medicare at 1-800-MEDICARE (1-800-633-4227; TTY/TTD: 1-877-486-2048) or visit the Medicare web site www.medicare.gov or call the Office of Ombudsman for Older Minnesotans at 1-800-657-3591.

WHEN YOUR MEDICARE COVERAGE ENDS

The nursing home staff gives you a Notice of Medicare Non-Coverage when they think you no longer qualify for Medicare coverage. However, if you think that you still need the skilled nursing level of care covered by Medicare, you have the right to have Medicare review the nursing facility’s opinion to decide if you still qualify.

The following steps must be taken:

1. The skilled nursing facility must send a claim called a Demand Bill to Medicare. When you receive the Notice of Non-Coverage, you can check off the box on this form that indicates you want a Demand Bill sent to Medicare.

2. Give this notice to the nursing staff.

3. The nursing facility sends the Demand Bill to Medicare.

4. Medicare decides if you still qualify for Medicare-covered skilled nursing care.

5. The nursing facility staff will inform you what Medicare’s decision is.

You must continue to pay for services that Medicare normally does not cover but you do not need to pay for services that Medicare may cover while waiting for Medicare’s decision.

If Medicare decides your care is no longer covered, you are responsible for the cost of the services you received while you were waiting for the decision.

If you disagree with the denial, you may file an appeal. The back of your Medicare Summary Notice or Notice of Utilization explains how to make an appeal. Because Medicare’s nursing home benefit requirements are complex, errors can occur that result in an incorrect denial of your Medicare benefits. Therefore, requesting a Demand Bill may result in the services being covered.

Call the Office of Ombudsman for Older Minnesotans for more information or for assistance with how to appeal a denial of Medicare benefits.