Requirements for Medicare Patients in Nursing Homes

Medicare, the federal program covering the medical needs of U.S. citizens over the age of 65, covers skilled nursing home costs only in certain circumstances. Medicare beneficiaries should look into so-called "Medi-Gap" insurance to cover co-payments for Medicare nursing home costs, or other long-term care insurance. Those patients without long-term care insurance must pay most nursing home costs out of pocket, until they have spent down their assets enough to qualify for federal Medicaid programs.

Qualifying Hospital Stay

• In some instances, Medicare will pay for skilled nursing home care. Patients must first have a qualified hospital stay of a minimum of three days just prior to their entrance into the nursing home. Patients must enter Medicare-qualified skilled nursing homes to be eligible for these limited benefits. Skilled care refers to physician-ordered treatment that must be performed by a nurse or physical therapist.

Coverage Limitations

• Only acute care patients are eligible for Medicare nursing home coverage. It does not cover people suffering from chronic conditions who are unlikely to improve or recover. Once a patient has been accepted in a Medicare-qualified skilled nursing home, coverage includes the cost of a semi-private room, three meals per day, rehabilitation and skilled nursing needs, and necessary medical equipment for 20 days. On the 21st day, patients will be subjected to a Medicare co-payment until day 100 of their stay in the nursing home. After day 100, Medicare will no longer pay for care and the patient is entirely responsible.

Written Notice of Non-Coverage

• If the nursing home believes a patient will no longer be eligible for Medicare coverage, by law they must give the patient a written notice of non-coverage. Patients cannot be discharged until 24 hours after receiving the notice. According to Senior Journal, the notice must include an explanation of how to file an appeal with a Quality Improvement Organization. Such an organization consists of physicians and other medical professionals monitoring Medicare patients and their level of care. An appeal should be made as soon as possible. Patients may need to hire an attorney should their appeal fail.