When Does Medicare Pay For Nursing Home Care?

One of the most tasteless phone calls I receive in the office is when someone's mother or father is admitted to the hospital. In this time of crisis, answers are not easy to come by.

How does their health assurance work? What does Medicare pay for? Once the parent is discharged, what happens, where do they go, how is it paid for, what are our options? What do we do if mom or dad is going to have to go to a nursing home? How do we pay for it?

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This obscuring is expected as the senior health care system can be a very confusing and phenomenal process. The first thing to do is to understand the basis for today's system.

In 1983, Congress created the Prospective payment System. This is foremost because when a someone 65 or older is admitted to a hospital, he is assigned only one of 473 Diagnostic linked Groups (Drg's). This is foremost because Medicare compensates the hospital a flat dollar whole for the Drg assigned to the patient.

Let me give you an example. Say that my father is admitted to the hospital with lung problems and the Drg is four days. If my father is discharged in three days, then the hospital makes one day of profit. If my father is discharged in five days then the hospital loses money and cannot bill the outpatient for the one extra day.

Back in the good old days, I remember when my grandfather was in the hospital and the nurse asked him if he felt well sufficient to go home because if he didn't, he could stay a few extra days until he felt better.

Today, it is all about the money. Once a outpatient is no longer getting better or worse, in other words, is deemed to be "stable", then the outpatient is discharged either to home or a Medicare certified nursing home or rehab facility.

In order for Medicare to pay for rehab care the outpatient must have been in the hospital for three consecutive days (72 hours). Then, no later than thirty days after dismissal from the hospital, be admitted to a Medicare certified nursing facility.

If these criteria are met, then for 2010, day's one through twenty in the rehab facility are paid for 100% by Medicare. For days twenty one through one hundred, your co pay is for this year is 7.00 per day.

From day 101 and beyond, regardless of your condition, you are responsible for all of the facility costs.

Keep in mind, that in order for this reimbursement schedule to happen, you must either be getting better or getting worse. Like the hospital, once you are deemed to be stable, you come off the Medicare reimbursement schedule and must pay for all costs.

In California, most patients will come off of Medicare reimbursement nearby week three and must begin incommunicable paying from this point forward. The firm office will advise you when this is expected to take place.

If the facility has long-term care beds, then the outpatient may be able to stay in the same facility. But if the facility is strictly short-term care or rehab, then the outpatient must find someone else facility or go home.

How does the patient's health assurance fit into this? It all depends on what type of plan that the senior outpatient is on. Is it a Medicare supplement plan or Ppo, or is it a Medicare advantage plan like an Hmo?

Medicare supplement insurance, also called Medigap, is incommunicable health assurance designed to supplement Medicare. A selected is paid for this coverage which is age rated.

There are twelve standardized Medigap plans, A through L. In most states, you can go to any physician or hospital that accepts Medicare without pre-authorization. Under plans C through J, days one through twenty are wholly paid for by Medicare. For days twenty one through one hundred, the Medicare co-pay for 2010 is 7.00 which is covered by the Medigap policy. From day one hundred one and beyond, the outpatient is responsible for the full cost.

For Medicare advantage plans such as an Hmo like gain Horizons, Scan and Kaiser, the patients may have a co-pay from day eleven of 0. It is best check the benefits booklet or call the customer assistance department.

If someone goes to a facility without going to the hospital first, then you must incommunicable pay from day one.

Once the outpatient comes off Medicare reimbursement, if qualified, Medi-Cal will help to pay for the nursing home costs. If going to the facility directly from home, then, if qualified, Medi-Cal may help to pay for the nursing home costs from day one.

Please consult with a Medi-Cal expert for more data and the exact procedures.

Copyright 2010 by Karl Kim

When Does Medicare Pay For Nursing Home Care?