What Happens When Medicare Stops Paying for Nursing Home Care: Navigating Next Steps
Understanding the limits of Medicare coverage is vital when considering the next steps for long-term care. If you or a loved one rely on Medicare for skilled nursing facility costs or rehabilitation, understand that this benefit is not indefinite. Medicare typically covers the total cost of a skilled nursing facility for the first 20 days of care following a qualifying hospital stay. However, the financial responsibility begins to shift to you after this period.
So what happens when Medicare stops paying for nursing home care? Your loved one either extends Medicare coverage, privately pays for the nursing home, applies for Medicaid to pay for the nursing home, or gets discharged to a lower level of care.
From day 21 to day 100 in a nursing facility, Medicare continues to contribute towards in-patient rehabilitation, but coinsurance payments are typically required from you. Additional coverage for days 21 through 100 depends on your Medicare supplemental or Medicare Advantage plans.
Once you reach day 101 or plateau in rehab, Medicare coverage for nursing home care ceases. You are responsible for all costs (easily $300-500 per day in Florida) unless you have additional insurance policies or qualify for other programs such as Medicaid. This can be a critical juncture, necessitating a review of your financial resources and possibly the need to explore alternative long-term care options.
Your planning for nursing home care should include understanding the limitations of Medicare and considering insurance or savings that can help cover long-term care. Without proper planning and decision-making, the financial impact can be significant, and a lack of adequate care from a short-term rehab discharge is a catastrophe.
Therefore, being informed and preparing for when Medicare will no longer cover these costs is crucial in ensuring that you or your loved one continues to receive the necessary care with minimal financial stress.
Understanding Medicare Coverage for Nursing Home Care
Navigating the specifics of Medicare coverage for nursing home care is crucial for effective planning.
Medicare Parts and Nursing Home Care Coverage
Medicare Part A is pivotal in covering inpatient care in a skilled nursing facility (SNF), provided certain conditions are met. It’s important to distinguish between the different parts of Medicare; Part A covers inpatient hospital stays, skilled nursing care, hospice care, and some home health care, but it does not cover long-term stays in nursing homes. A long-term stay means that your loved one is not able to go home and requires 24/7 care that your nor an assisted living facility can provide.
Eligibility Requirements for Medicare Coverage
To qualify for Medicare Part A coverage of nursing home care, you must first have a qualifying inpatient hospital stay. This means an inpatient hospital stay of three consecutive days or more, not counting the discharge day.
Following this, if you require skilled care, you may be eligible for coverage in a Medicare-certified skilled nursing facility. You should know by now if there is a problem with the duration of the hospital stay, but be sure to ask if you are unsure.
Limits of Medicare Part A Coverage
Coverage under Medicare Part A for a skilled nursing facility is not indefinite. It’s provided for a limited time during a benefit period. A benefit period begins the day you’re admitted as an inpatient to a hospital or skilled nursing facility and ends when you haven’t received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. This rule is tricky but applicable when your loved one has gone through the elder care carousel: in and out of hospitals, rehab facilities, and homes in the last few months.
If you need professional care again after a benefit period has ended, a new benefit period begins, and you must meet the qualifying hospital stay requirement again. There are also limits on the coverage provided, typically up to 100 days per benefit period, with a co-insurance fee kicking in after day 20.
What Happens When Medicare Stops Paying for Nursing Home Care?
When your Medicare coverage for a nursing home ends, it’s critical to explore your options carefully to ensure continued care while managing your finances.
Sometimes, nursing home staff will have you feeling bullied at this point – but you will be ready if you read this article.
Should You Pay Privately for a Nursing Home?
If Medicare stops covering your stay in a skilled nursing facility, you may consider paying privately for your care. This means using resources like savings, stocks, bonds, annuities, IRAs, or selling real estate to cover costs. This is not recommended, and you should hire an elder law attorney to help you apply for Medicaid and protect assets.
It’s essential to assess whether your assets can support long-term out-of-pocket expenses. This, however, is not sustainable in the long term, and usually, folks with high incomes and long-term care insurance coverage can absorb $10,000 to $13,000 a month in nursing home bills.
Medicaid and Nursing Home Care
For many individuals, Medicaid becomes a crucial resource when Medicare coverage ends. Nursing home Medicaid eligibility requires meeting certain income and asset criteria under Florida law. It can cover long-term care costs in a nursing facility if you qualify. Understanding the qualifications and application process is essential for a smooth transition. Contact us if your loved one is located in Northeast Florida and we can help you qualify for Medicaid even if your assets or income are too high.
Long-Term Care Insurance
Long-term care insurance may offer a financial safety net if purchased before requiring nursing home care. This type of insurance can cover expenses that Medicare does not, potentially easing the financial burden significantly. Check your policy for coverage details and ensure it aligns with your care needs.
Transition to Other Care Locations
If ongoing nursing home care is not financially sustainable, consider alternative care settings. Depending on the level of care needed, options such as assisted living, home health care, or community services may be more viable. It’s essential to research each option and evaluate if they fit within your budget and care requirements. Contact us if your loved one is in Northeast Florida and you are looking to assess options to transition to a different level of care.
Financial Planning for Continued Nursing Home Care
When Medicare coverage concludes, navigating the financial realm of continued nursing home care is essential. Let’s examine critical steps and considerations to manage the necessary expenses effectively.
Understanding Medicaid Spend Down
Medicaid planning can be a lifeline for nursing home care once Medicare ceases payment. Medicaid planning is a subspecialty of elder law. However, the transition requires an understanding of the Medicaid Spend Down process. You might need to “spend down” your assets to meet Medicaid’s eligibility criteria. This typically involves reducing your countable assets, including bank accounts, stocks, and other countable investments, to a level within Medicaid’s limits.
Essential items like your home, a vehicle, personal belongings, and specific life insurance policies are generally exempted. Planning early with an explicit knowledge of regulations can prevent last-minute financial strain. However, last-minute options can still help you qualify for Medicaid, even if your loved one has too much money or their income exceeds the limit.
Privately Paying for Nursing Home Care
If Medicaid is not immediately available or you choose not to use it, you may need to pay for care out of pocket. This could mean tapping into savings accounts or selling assets like bonds and stocks. Evaluating your liquidity and anticipating monthly nursing home costs will help maintain financial stability during this period.
It’s essential to consider the sustainability of this method, as nursing home expenses can rapidly deplete resources. Also, consider the tax benefits of utilizing certain assets to pay for care.
Evaluating Assets and Investments
A thorough evaluation of your assets and investments is a critical step in long-term nursing home care planning. You need to know what you have, the value of each asset, whether they generate income, and how they can be utilized or liquidated if necessary. In some cases, annuities and life insurance policies may offer options for cash-out or loans, which can provide financial support without necessarily liquidating the assets.
Assessing real estate owned and whether it aligns with Medicaid’s asset rules is also critical. You may want to consult an elder law attorney regarding nursing home Medicaid planning for tailored guidance.
In this section, we’ve navigated the complexities of financial planning for nursing home care after Medicare stops paying, such as understanding Medicaid rules, using personal funds, and evaluating assets. Each step requires due diligence and a keen understanding of both financial products and your circumstances to ensure continual care without unnecessary financial hardship.
Addressing Continuity of Care
When Medicare no longer covers your stay in a nursing home, it’s crucial to have a plan in place to ensure ongoing care. This could involve long-term care planning, exploring in-home assistance, and understanding your legal rights.
Planning for Long-Term Nursing Home Care
If you or a loved one is facing dementia or requires memory care, planning for long-term nursing home care becomes critical. Assess financial options like private insurance and Medicare benefits to understand how long they will cover care and what services are included. Consider the role of Medicaid if available assets and income become depleted. Research local facilities that offer comprehensive nursing home services tailored to dementia patients to find suitable options ahead of time.
Understand that both nursing homes and assisted living facilities can provide memory care. “Memory care” is not a license that the State of Florida issues. The term “memory care” is a specialization that individual assisted living facilities or nursing homes use.
Community and In-Home Alternatives
Once Medicare coverage ends, community services and in-home care can offer viable alternatives to nursing home care. Look into community resources like adult day care programs or assisted living services, which can provide essential support while allowing more independence. Ensure you know the difference between a nursing home and an assisted living facility.
In-home care, which includes medical and non-medical assistance, can also be a flexible and often more affordable option that lets you remain in a familiar environment.
Usually, these options won’t work financially if your loved one is bed-bound and requires 24/7 care or supervision. In-patient Hospice is an option only during someone’s last days of life, and in-patient Hospice will provide 24/7 care. Palliative care services could also give extra support, but the care is limited.
Legal Rights and Medicare Non-Coverage
Understanding your legal rights concerning Medicare non-coverage is essential. Familiarize yourself with the notice of Medicare non-coverage and know why Medicare ends payment. You have the right to an appeal, and knowing the procedures can make a significant difference in managing the transition from Medicare-funded care.
Frequently Asked Questions
When Medicare stops paying for nursing home care, you’ll face essential decisions on managing and funding continued care. Understanding your options and obligations is crucial for uninterrupted care.
How can one continue paying for nursing home care after Medicare coverage?
After the end of Medicare coverage, you can continue paying for nursing home care out of your pocket. Personal savings, retirement funds, or family help can be immediate solutions. Alternatively, you can look towards Medicaid eligibility and use an elder law attorney to help qualify and protect assets.
What alternative funding options for nursing home care when Medicare is exhausted?
Other funding options include Medicaid, if you qualify, or long-term care insurance. Veterans’ benefits or community resources like PACE (Program of All-inclusive Care for the Elderly) might also be available.
What is the duration of Medicare coverage for skilled nursing facilities?
Medicare covers skilled nursing facility care for a limited period following a qualifying hospital stay, typically up to 100 days per illness, with decreasing coverage after the 20th day.
What types of care will a patient need to pay for out-of-pocket after Medicare stops covering nursing home care?
You will need to pay for custodial care—such as assistance with daily activities and routine care—if other sources like Medicaid or private insurance do not cover it.
How does one apply for Florida Medicaid to cover nursing home care costs?
To apply for Florida Medicaid to help with nursing home care, contact your local Florida Department of Children and Families office or use the ACCESS Florida online system to determine your eligibility and submit an application. For families that exceed the income and asset limits, you should use an elder law attorney to apply and assist with the transfer of assets.
What happens if you do not pay for nursing home care or get Medicaid?
Failure to pay for nursing home care may lead to discharge planning and seeking alternative living arrangements, which can include a homeless shelter. If Medicaid is not an option, you may need to explore other alternative funding sources, such as selling assets or assistance from family.
