Medicare Part A covers institutional care in hospitals,
skilled nursing facilities, care given by home health
agencies, and care provided in hospices.
Any individual who has reached 65 years of age and is
entitled to Social Security benefits is eligible for Medicare
Part A without charge. This means that there are no premiums
for this particular part of the Medicare program.
Medicare Part A covers up to one hundred (100) days of
“skilled nursing” care. However, the conditions for obtaining
Medicare coverage of a nursing home stay can be quite
stringent. Here are the main requirements:
1. The Medicare recipient must enter the nursing
home no more than thirty (30) days after a hospital stay that
lasted for at least three days (not counting the day of discharge).
During the hospital stay you must have been admitted as an
inpatient, meaning you were not simply there for observation.
2. The care provided in the nursing home must be
for the same condition that caused the hospitalization
(or a condition medically related to it).
3. The patient must receive a “skilled” level of care in the
nursing facility, which could not be provided at home or on an
outpatient basis. In order to be considered “skilled,” nursing care
must be ordered by a physician and delivered by a physical therapist,
registered nurse or licensed practical nurse. Moreover,
such care must be delivered on a daily basis.
As soon as the nursing facility determines that a patient is no
longer receiving a “skilled” level of care, the Medicare coverage
will lapse. Furthermore, beginning on day twenty-one (21) of the
nursing home stay, there will be a significant copayment equal to
one-eighth of the initial hospital deductible ($148 a day in 2013).
This copayment will usually be covered by a medigap insurance
policy, provided the patient has one.
Nursing homes often terminate Medicare coverage for skilled nursing
facility care before they should. There are two main misunderstandings
that most often result in an inappropriate denial of Medicare coverage
to skilled nursing facility patients. First, many nursing homes wrongfully
assume that if a patient stops making progress towards recovery then
Medicare coverage should be terminated. In fact, if the patient needs
continued skilled care simply to maintain his or her status
(or to slow deterioration) then the care should continue to be
provided and is covered by Medicare.
Secondly, nursing homes may mistakenly believe that care requiring
only supervision (rather than direct administration) by a skilled nurse
is excluded as a benefit from the Medicare’s skilled nursing facility program.
Moreover, patients often receive an array of treatments that do not
need to be carried out by a skilled nurse, but that may require skilled
supervision. As a result, Medicare will continue to provide coverage
if the potential for adverse interactions among multiple treatments
requires that a skilled nurse monitor the patient’s care and status.
As a patient leaves a hospital and moves into a
nursing home that provides Medicare coverage, the
nursing home must give the patient written notice of whether
the nursing home believes that the patient requires a skilled
level of care, and thus merits Medicare coverage.
In cases where the skilled nursing facility initially treats the
patient as a Medicare recipient, after two or more weeks,
often, the skilled nursing facility can determine that the
patient no longer needs a skilled level of care and will
issue a “Notice of Non-Coverage” terminating the
Medicare coverage.
Whether the non-coverage determination is made on
entering the skilled nursing facility or after a period of
treatment, the notice asks whether the patient would
like the nursing home bill to be submitted to Medicare
despite the nursing home’s assessment of his or her care
needs. The patient should always ask for the bill to be
submitted. This requires the nursing home to submit the
patient’s medical records for review to the fiscal
intermediary, an insurance company hired by Medicare,
which reviews the facilities determination.
The review does not cost the patient anything, but could
result in more Medicare coverage. While the review is being
conducted, the patient is not obligated to pay the nursing home.
However, if the appeal is denied, the patient will owe the
facility retroactively for the period under review. If the fiscal
intermediary agrees with the nursing home that the patient no
longer requires a skilled level of care, the next level of appeal
is to an Administrative Law Judge. This appeal can take a year
and involves hiring a lawyer. It should be pursued only if, after
reviewing the patient’s medical records, the lawyer believes
that the patient was receiving a skilled level of care that should
have been covered by Medicare. If you are turned down at
this appeal level, there are subsequent appeals to the
Appeals Council in Washington, and then to federal court.
For more information regarding Medicare nursing home
coverage decision making please contact
Douglas L. Kaune, esquire at 610 933 8069 or
email me at dkaune@utbf.com.
Unruh, Turner, Burke & Frees, P.C. is a full service
law firm which has three convenient office locations in
Phoenixville, West Chester and Malvern, Pennsylvania.
The firm primarily services clients in Chester,
Montgomery, Delaware, Philadelphia, Bucks and
Berks Counties, but can represent clients throughout Pennsylvania.
