Davan Enterprise Insurance Agency Blog

Medicare Part A provides benefits for SNF if certain requirements are met.

• Have been in a hospital inpatient ( as opposed to being inthe hospital for observation) for at least three consecutive days (not counting the day the patient is released) before being admitted to a Medicare - certified skilled nursing facility.
• Be admitted to a SNF within 30 days of discharge from the hospital.
• Require daily skilled care that can only be provided as an inpatient in this type of facility.
• Be certified by a doctor or appropriate medical professional as requiring skilled nursing services on a daily inpatient basis.
• Be treated for the same illness or condition for which they were a patient in the hospital (even if it was not the reason the person was admitted to the hospital).

For many years facilities would apply the "Improvement Standard" however in Jimmo v Sebelius that changed.  Medicare will cover skilled care provided in a skilled nursing facility, at home, or as outpatient therapy, regardless of whether a patient is likely to improve as long as they continue to meet qualifying criteria.

Medicare's coverage of a skilled nursing facilty stay is limited to a maximum of 100 days per benefit period.

The benefit period can sometimes be referred to as a spell of illness.

• Begins the first day that a beneficiary receives inpatient hospital or SNF care.
• Ends when a beneficiary has not been in a SNF or hospital for at least 60 days in a row (or, if a person remains in a SNF, when he or she hasn't received skilled care there for at least 60 days in a row).

There is no limit to the number of benefit periods available to Medicare Beneficiaries.  However, once a benefit period ends a beneficiary must have another three-day qualifying inpatient hospital state and meet the other requirements noted earlier before they can get another 100 days of SNF benefits.

If a person is released or no longer needs SNF but then later requires the SNF care again:

• Less than 30 days - The person doesn't need a new three-day inpatient stay to qualify for additional SNF coverage, but they need to continue to meet all the over coverage requirements.
• 60 Days or more - Medicare will not cover additional SNF care unless the person has a new three-day qualifying inpatient hospital stay and meets all other coverages if a break lasts for 60 consecutive days in a row.

Medicare Part A does have  a deductible that must be paid for any hospital admission and those rates can change from year to year.  You can visit cms.gov to check the current Medicare Part A deductible.

Medicare pays for the first 20 days of skilled nursing facility care, with no deductible or coinsurance.  However, the patient is responsible for daily co-payments after the twentieth day.  For 2023, the daily SNF co-payment was $200 for days 21 through 100.  After 100 days in a benefit period, the beneficiary must pay all costs.

Medicare Supplement plans, Medicare Advantage Plans, or Supplemental Hospitalization plans can help reduce these costs if you have one of those plans for an additional monthly premium.

Medicare will pay for home health care if a person meets certain eligibility criteria and if the services are considered resaonable and necessary for the treatment of the person's illness or injury.

• Home Care - means services of a personal (nonskilled) care provider for assistance with activities of daily living (such as bathing, eating, dressing, continence, and transporting) or incidental activities of daily living (such as housekeeping, laundry, bill-paying, grocery shopping, etc).
• Home Health Care - addresses the needs of an individual for professional care including that of a  registered nurse, physical therapist, speech therapist, occupational therapist, or doctor for medically necessary in-home visit.

Medicare covers home health care; it does not cover home care when personal care is the only type of care needed.

To receive Medicare-covered home healthcare benefits, a person must be eligible for and enrolled in Part A and/or Part B.  The following requirements must also be met:

• A qualified medical professional must certify that skilled care isneeded and must prescribe the plan of care.
• The services provided must be by a participating Medicare-approved home healthcare organization.
• The patient must need at least one of the following; Intermittent skilled nursing care, physical therapy, speech language pathology, continued occupational therapy.
• The patient must be confined to the home (homebound).

Home Health Aide Services:

• Simple dressing changes
• help with medications that are self-administered
• assistance with activities that are directly supportive of skilled therapy, such as routine exercises and practicing functional communication skills
• routine care of prosthetic or othotic devices.

Medical Social Services -  Ordered by a doctor to help a person with various social and emotional concerns related to an illness that may interfere with the person's treatment or recovery.

Physical, Speech-Language, and Occupational Therapy - If ordered by a doctor.

Excluded Services:

• 24-Hour per day care at home
• meals delivered to the home
• homemaker services like shopping, cleaning, and laundry
• personal care given by home health aides (like bathing,, using the toilet, or help in getting dressed) when this is the only care needed.

There is no limit to the length of time that a person can receive home healthcare benefits.  Once a person meets the initial qualifying criteria.

Recertification is required at least every 60 days when the patient needs continuing home healthcare.

Begining in 2019, CMS expanded the definitional scope of "supplemental benefits" that Medicare Advantage plans can offer.  But all Medicare Advantage plans are not same as they may have different rules, costs, and restrictions on services but required to provide at least the same level of coverage as Original Medicare (Part A & B).

Additional Services that may be included with your Medicare Advantage plan:

Adult Day Care Services - services provided outside the home, such as assistance with activities of daily living and instrumental activities of daily living.

In-Home Support Services - services performed by a personal care attendance to assist disabled ormedically needy individuals with ADL's.

Home- Based Palliative Care - services not covered by Medicare in the home for palliative care ("comfort care") to diminish symptoms of a terminally ill enrollee with life expectancy of more than six months.

Transportation for (nonemergency) Medical Services - transportation to obtain Part A, Part B, Part D, and supplemental benefit items and services.  It can not be used for non-medical services such as groceries and errand.

Home Safety Devices and Modification - safety devices to prevent injuries in the home an/or bathroom.