Many people assume that the cost of nursing home care will be paid for by Medicare. Although Medicare does cover nursing home care in some instances, there are strict guidelines about what and when they cover care in a facility. Before Medicare will cover the cost of a nursing home, the person must have been admitted to the hospital for at least three days. For that to happen, the person has to meet the Medicare standards that require acute hospital admission. After being in the hospital, the doctor has to certify that the patient needs skilled nursing care after the hospital stay. This isn't something the doctor can just say. The patient's condition has to fall within certain categories that have been determined to be "skilled" needs. The skilled care must be required on a daily basis and it has to be a service that is considered too complex, or too dangerous to be done safely in the person's home. The fact that there may not be any one in the person's home to provide any type of service doesn't qualify him/her for nursing home payment.
Examples of skilled nursing care are: management of changing, complex care plans; tube feedings; therapeutic exercises; and ambulation evaluation and training. Many of the services families are seeking when the decision to utilize nursing home care is made, such as help managing incontinence, help with bathing and dressing, monitoring of daily activities, are not considered skilled care and do not qualify as Medicare reimbursable services in a nursing home.
If you have time to plan for a nursing home admission, explore alternate funding for nursing home care. Medicare may not be an option. If you are denied coverage in a nursing home by Medicare, you can appeal the decision if you think the person's care meets the level of skilled care. The Center for Medicare Advocacy (860- 456-7790) can help you with the appeal process.
