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Medicare

Medicare is a health insurance program for people 65 or older or people under 65 with certain disabilities or end-stage renal disease. Medicare doesn’t cover all expenses and is not designed to pay for long-term custodial care, so it’s important to understand the program.

Medicare’s premium, deductible and co-insurance amounts change each year. Medicare pays for 100 percent of days 1-20 of a qualifying skilled nursing stay, but there is a co-insurance charge for days 21-100. Our admissions team can review the current rates and coverage with you.

Current rates are also available at medicare.gov or click on this link for current Medicare Rates.

Understanding Medicare

  • Medicare Part A—helps pay for hospital stays, skilled nursing facility care, home health care and hospice care.
  • Medicare Part B—helps pay for doctors' services and outpatient care, as well as some other services such as physical and occupational therapy, some home health care, and services and supplies that are medically necessary.
  • Medicare Part C—is Medicare’s managed care benefit called Medicare Advantage plan. Each plan offers different benefits and different rules than traditional Medicare.
  • Medicare Part D—is the Medicare prescription drug coverage program. The cost and coverage vary by plan. 

Coverage

Medicare offers an opportunity to receive quality health care for a wide range of conditions including inpatient skilled nursing and rehabilitation services. Medicare helps pay for some skilled nursing care costs such as:

  • Semi-private room
  • All meals, including special diets
  • Use of items such as braces, splints and adaptive equipment
  • Medications prescribed by physician
  • Medical supplies
  • Nursing care
  • Rehabilitation services including physical, occupational and speech therapies 

Qualifying

A patient can qualify for Medicare benefits under most circumstances if:

  • The person has been in the hospital for three consecutive days, not counting the day of discharge.
  • The person is transferred to a nursing center for further care of the condition that was treated in the hospital or other conditions requiring skilled nursing or rehabilitative services.
  • A physician certifies the patient requires skilled or rehabilitative care after the hospital stay.

30-Day Rule or Window

You may be able to return as a Medicare recipient within 30 days of discharge without the need for another hospital stay, if you have Medicare days remaining and you need skilled services again in accordance with your physician’s orders.

60-Day Rule or Follow-Up Care

If you are hospitalized for three or more days within the next 60 days, you may be able to return to a skilled nursing center to begin using your remaining Medicare days, as long as you need skilled care. If it has been more than 60 days since you have left a facility, you may qualify for a new 100-day benefit from Medicare, if you have met the criteria above and have had 60 consecutive days of non-skilled services between hospital or rehabilitation stays. 

Hospital Observation Stays

Hospital observation stays are outpatient services to help a physician decide if the patient needs to be admitted as an inpatient for more treatment or if the patient can be discharged. Care is usually provided in an emergency room or other area of the hospital. In order to receive Medicare coverage for a skilled nursing center stay, you must be admitted as an inpatient for three consecutive days and require skilled care. You should always ask your physician if you have been formally admitted. You may be covered for skilled care through a secondary insurance provider, Medicaid or veteran’s benefits, or you may pay privately. Medicare Part B will cover any required therapy services needed.

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