What are the requirements for Medicare to pay for a nursing home?

When it comes to caring for a beloved family member, managing their health condition, and juggling their declining health, having to deal with Medicare's coverage for skilled nursing facility care can be quite overwhelming. Knowing precisely what benefits Medicare provides and where the gaps are can help inform decisions your family makes regarding a loved one’s increasing care needs, potentially saving thousands of dollars.  

Medicare Coverage of Skilled Nursing Facilities  

Custodial care or long-term residential care is not covered under Medicare; skilled nursing facilities are covered under very specific conditions. Unlike Medicaid or private insurance, Medicare has strict limitations regarding the coverage of skilled nursing facility stays and does not provide coverage simply because a loved one needs assistance with daily living.  

Medicare does pay for skilled nursing services, which are provided by licensed healthcare professionals like registered nurses, physical and occupational therapists. This is in stark contrast to custodial care, which assists with bathing, grooming, and bringing food to a patient.

The 3-Day Requirement For Staying in the Hospital

One of the most important Medicare policies is the 3-day mandatory qualifying hospital stay. This policy entails that your patient needs to be an inpatient of the hospital for at least 3 consecutive days before Medicare can cover the rest of the skilled nursing facility care.  

Day surgeries, ER visits, and observation stays are not included. The hospitalization needs to be for the same reason or for a related reason that would require skilled nursing facility care.  

Important Medicare Policy Gaps For Eligibility  

Medically Necessary Documentation

Medicare does not cover the costs of skilled nursing care unless the patient meets specific criteria that require detailed documentation. Documentation needs to be provided that the patient to the skilled nursing facility meets the following criteria:  

• The patient requires skilled nursing care or rehabilitation therapy.  

• Skilled nursing care can only be provided in an institution.  

• The patient must qualify for the care, showing potential to improve or maintain a certain level of function.  

• The services must be ordered by a qualified physician.  

Healthcare providers must justify and provide detailed care plans describing the skilled services to be provided, how often, and for what duration. This documentation is the basis for the Medicare approval.

Categories of Covered Services

Medicare provides coverage for specific types of skilled services offered in nursing facilities:  

Skilled Nursing Care: The professional nursing services that skilled nurses perform include evaluating and treating patients, performing their medical assessments, and managing chronic and complex issues.  

Rehabilitation Therapies: Rehabilitation services can include physical, occupational, special education, and speech therapy in the appropriate areas of health and post-illness recovery.  

Medical Equipment and Supplies: Medicare offers coverage for durable medical equipment, medications, and other supplies needed for the skilled services that are performed.  

Coverage Period and Restrictions  

The 100-Day Benefit Period  

Medicare Part A provides coverage for skilled nursing facilities for up to 100 days within each benefit period, but there are important cost-sharing rules:  

• Days 1-20: All approved costs are covered in full.

• Days 21-100: The beneficiary starts to incur a small daily coinsurance fee. ($204.00 a day in 2024)  

• After Day 100: Coverage is terminated until out-of-pocket coverage starts again.  

Reset Rules for Benefit Periods  

After a 60-day break from skilled nursing facility services, a new benefit period starts. If the patient is discharged from the facility and does not need nursing services for 60 days, they can become eligible for another 100 days of covered nursing facility services.

Looking For Nursing Homes Alternative When They Are Not Covered By Medicare

Community Care Programs

When Medicare coverage isn’t available, families tend to look into community care options. These programs are designed to help seniors who are physically unable to leave their homes or their family members, to ensure they are safe and properly cared for. 

Community-based services, or services that are community-based, include but are not limited to adult-day services, meal delivery services, home or community-based transportation, and safety-assuring social and recreational activities. 

Home Health Care Solutions 

The home health care problem is a more affordable solution to problem care facilities and institutional care, most of the time for the elderly. As long as the home health services are qualified, Medicare will reimburse home health services that meet the following conditions:

• The patient has to be homebound

• There has to be a physician ordering the services 

• There has to be skilled nursing, therapyy or other qualified services required

Able home health care nurses can offer skilled medical services at the patient’s home, such as administering medications, wound care, and other necessary health checks as required.

Personal Care Services

Unfortunately, Medicare does not cover personal care for seniors, but knowing what services are available can assist families with planning. Personal Care Assistants help with non-medical daily living activities, which include, but are not limited to, the following:

• Assisting with bathing and grooming

• Meal planning and nutrition assistance

• Light cleaning and laundry

• Supplying medication reminders

• Providing companionship and social interaction

These services, which are typically covered by Waivers and self-pay, can help seniors stay at home for a longer period of time and improve their safety. 

Victorian Gardens: Excellence In Senior Care Services

While looking at available nursing services, it is hard not to notice Victorian Gardens, a leader in comprehensive senior care. Their unwavering commitment to satisfaction and quality care has made them a reputable name in the business.

Victorian Gardens provides its residents with comprehensive services from skilled nursing and rehabilitation therapies to ensure appropriate and personalized attention. The team is very familiar with Medicare and ensures to help families take full advantage of the coverage available.

The facility places great importance on health care with a focus on dignity and comfort, and clinical excellence. Care teams include, at a minimum, a registered nurse, therapist, social worker, and other relevant skilled professionals who together design and execute personalized care plans.

Victorian Gardens offers educational materials and helpful information to families looking for reliable resources on nursing services and Medicare coverage. To understand Victorian Gardens nursing services and their comprehensive care options, including assistance with Medicare questions, visit their website.   

Planning: Financial Strategies for Long-Term Care  

Long-Term Care Insurance  

Due to Medicare’s scant coverage for nursing home care, most financial advisors suggest acquiring long-term care insurance while still in good health. These plans often cover both institutional and community-based care services.  

Medicaid Planning  

For families with limited financial resources, planning for Medicaid becomes crucial. Unlike Medicare, Medicaid covers long-term custodial care, but stringent income and asset limits must be met to qualify.  

Family Care Coordination  

Care coordination engages several family members in planning and may include hiring care managers who specialize in elder care. These specialists help families facing complex systems by providing system navigation, care coordination, and care continuity.

Top Reasons For Medicare Denial and How to Appeal 

Comprehending Denial Letters 

There are several reasons why Medicare may deny coverage: 

• Lack of relevant medical supporting documents 

• Services are considered custodial, not skilled

• Missing the 3-day inpatient hospital stay prerequisite

• Concern regarding the patient’s improvement potential

The Appeals Steps

All Medicare members are entitled to appeal coverage denials, and there’s a defined pathway that they can follow: 

1. Reconsideration: Appeal decision to another contractor

2. Administrative Law Judge Hearing: Independent assessment 

3. Medicare Appeals Council Review: Additional administrative evaluation 

4. Federal District Court: Case-specific monetary threshold determines final appeal eligibility

Making Smart Choices Regarding Senior Care

Understanding the Medicare guidelines pertaining to nursing home care gives families the ability to make the right decisions regarding the care of their loved ones. While there are limitations to coverage, understanding eligibility qualifications can help navigate and leverage benefits. 

Medicare does not cover long-term custodial care; rather, it generally covers skilled medical services. Understanding this difference helps with care evaluation, financial planning, and strategy development.

To help you understand skilled nursing services and how Medicare coverage applies to your particular case, it is worthwhile speaking with professionals who focus on caring for older adults. Family-owned Medicare brokerage firms that are specific to Victorian Gardens offer helpful information and work with families to help them explore available options in the complicated world of healthcare.  

Understanding important Medicare guidelines to care for seniors in advance, record-keeping, and having an informed healthcare team are the building blocks of successful Medicare navigation. With the right strategies and information, families can help ensure that older adults receive the quality healthcare services they need, and families are able to maximize available benefits.  

FAQs

1. Does Medicare pay for nursing home care?
Medicare does not cover custodial or long-term residential care. It only covers skilled nursing facility (SNF) care under specific medical conditions and eligibility requirements.

2. What type of care does Medicare cover in a nursing home?
Medicare covers skilled nursing care, rehabilitation therapies (physical, occupational, speech), and necessary medical equipment or supplies — but only if these services are medically necessary and ordered by a qualified physician.

3. What is the Medicare 3-day hospital stay requirement?
Before Medicare will pay for SNF care, the patient must have been admitted as an inpatient in a hospital for at least 3 consecutive days (not counting the discharge day). ER visits, observation stays, and day surgeries don’t count toward this requirement.

4. How long will Medicare cover a nursing home stay?
Medicare Part A covers up to 100 days per benefit period:

• Days 1–20: 100% covered

• Days 21–100: Patient pays a daily coinsurance ($204/day in 2024)

• After Day 100: No coverage until a new benefit period begins
  
  

5. When does a new Medicare benefit period start?
A new benefit period begins after the patient has gone 60 consecutive days without receiving inpatient hospital care or skilled nursing facility services.