Why is the nursing home billing us when mom has Medicare?

Elderly woman holding handAnswer:  Medicare covers some eligible nursing home costs – not all.  Maybe she has been there over 20 days or no longer qualifies for “skilled” care.

Recently I received an email requesting assistance for a client’s mother who had just had a stroke. She lived alone and could not return to her home. The family, like many others in similar situations, did not realize what the potential cost of nursing home care.  It is important to understand the different kinds of long term care.

Skilled Nursing (SNF) — Skilled care is a term that refers to a patient’s care or treatment that can only be done by licensed nurses or other licensed professionals.  Examples of skilled care include complex wound dressings, rehabilitation, tube feeding, intravenous or intramuscular injections, nasopharyngeal and tracheotomy aspiration, etc.

Intermediate care (ICF) – Intermediate care refers to custodial care for individuals unable to care for themselves due to physical or mental impairments or disabilities. Medicare does not provide reimbursement for this type of care.  Coverage is usually through personal funds, long term care insurance or Medicaid.

The available Hawaii State Health Planning and Development Agency Utilization Report from 2016 listed long term care daily room rates as follows:

 Skilled Nursing*  ICF Care *
Private Semi-Private Ward      Private Semi-private Ward
$450 $443 $380 $420 $411 $365

*Average costs

Rates have increased each year.  Currently costs could run from $130,000 – $180,000 annually.

 

If you have Medicare and need skilled nursing care you would pay the following:

  • Days 1 – 20: $0 for each benefit period
  • Days 21 – 100: $0 to $167.50 per day depending on the supplemental or Advantage plan you selected.
  • Days 101 and beyond: you pay all costs

Before qualifying for Medicare benefit payments, a 3-day hospital stay is required.

By Edwina Lee RN, MSN Crown Care Hawaii

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