OVERVIEW
The Medicare Program (Part A — Basic Hospital Insurance) helps provide up to 100 days of skilled nursing care per benefit period in a "certified skilled nursing facility."
What exactly is a "certified skilled nursing facility"?
A certified skilled nursing facility, also known as a SNF, provides daily skilled nursing care of skilled rehabilitation services to people age 65 or over as well as the disabled and younger individuals recovering from strokes, accidents, hip and knee replacements. It has been certified under the Medicare Act to meet high standards for care. It may also be be a specially qualified long-term care facility, or part of a hospital or a rehabilitation center.
Why are such skilled nursing facilities needed?
Because they provide the necessary level of medical and round-the-clock nursing care for the patient who does not require the specialized care of a hospital — at a greatly reduced cost. They also free hospital beds for others.
To be "certified" under the Medicare program, a skilled nursing facility must meet these standards:
It must be licensed in accordance with state and local laws, including all applicable laws pertaining to staff, licensing, and registration, fire, safety, communicable diseases, etc.
It must have a governing body legally responsible for policies and the appointment of a qualified administrator.To cover an emergency it must have one or more physicians on call at all times.
It must have 24-hour nursing care services.
There must be:
Enough nurses on duty at all times, including at least one registered nurse employed full-time;
A registered nurse or qualified, licensed practical nurse in charge of each tour of duty;
A continuing educational program for all nursing personnel.
Resident rights. It must inform residents of their rights — and protect those rights.
Quality of care. It must periodically assess each resident's capacity to function and promote the resident's well-being and quality of life.
Dental care. It must assist residents in getting needed routine and 24-hour emergency dental care.
Infection control. It must have an infection control program.
Hospital transfer. It must have an agreement with one or more participating hospitals for transferring patients when such transfer is medically determined by patients' physicians.
Drugs. It must have appropriate methods for obtaining and dispensing drugs and biologicals according to accepted professional standards.
Records. It must maintain a separate and confidential clinical record for each patient.
Rehabilitation services. It must provide skilled rehabilitation services to help the patient maintain and improve functional abilities.
Social services. It must identify the patient's need for medically-related social services. It then provides such services (by its own staff) or refers the patient to a provider of social services.
Other services. It must have arrangements for obtaining required clinical, laboratory, x-ray and other diagnostic services.
Food. It must serve adequate food to meet dietary needs of patients. A qualified person must prepare food in compliance with all sanitary and safety codes.
Activities. It should encourage self-care and the patient's return to normal life in the community via social, religious, and recreational activities, and by visits with relatives and friends.
Building and maintenance. The facility must be constructed, equipped and maintained to ensure a safe, functional, sanitary and comfortable environment for patients. Fire rules must be posted.
Admission practices. The facility must admit eligible patients regardless of race, color, or national origin.
Goals of a certified nursing facility include high-quality health care — 24 hours a day — in a comfortable, cheery, safe environment with recreational programs to fit needs.
How do I qualify for skilled nursing care under Medicare?
First, you must be eligible for Medicare. You're eligible if you are:
Age 65 or older and have worked long enough to be insured under Social Security, the railroad retirement system, or federal employment.
Under 65 and have been getting Social Security disability benefits for more than 24 months.
Already receiving benefits from Social Security or the railroad retirement system.
Entitled to Medicare because of permanent kidney failure.
If you're eligible for Medicare, both Part A and Part B insurance can help pay for skilled nursing care if a medical professional certifies that you need skilled nursing or rehabilitation services on a daily basis, and:
Your care, as a practical matter, can only be provided in a skilled nursing facility;
You have been in a hospital for at least 3 days, not including the day of discharge;
You are admitted to the skilled nursing facility within a limited period (generally 30 days) after the hospital stay;
Your care in the skilled nursing facility is for a condition that was treated in the hospital;
The Medicare fiscal intermediary does not disapprove your stay.
Medicare Program Part A Basic Hospital Insurance
Helps pay for up to 100 days of skilled nursing care per benefit period* (if you need and receive daily skilled nursing care or rehabilitation services for that long). For the first 20 days, Part A insurance pays all covered costs. For the next 80 days, Part A insurance pays all covered costs beyond $170.50 a day, (this amount changes every year). The length of time covered is dependent on the amount and type of skilled care required and is subject to medical necessity review by the Medicare fiscal intermediary.
Covered Services Include:
Room and board in semiprivate (2 to 4 beds in a room)
Therapy — physical, occupational, speech
Nursing care by skilled nurses (but not private duty nurses)
Medical social services
Drugs, supplies, appliances, blood transfusions, etc., usually furnished to patients by facility.
* A benefit period begins the first day you receive inpatient services and ends when you've been out of the hospital and have not received skilled services in any other facility for 60 days in a row.
Medicare Program Part B Voluntary Medical Insurance
Pays for most of the bills for covered services of physicians and surgeons, as well as other services such as outpaitnet hospital, certain home health services, rural health clinic services, ambulatory surgical center services, comprehensive outpatient rehabilitation facilities and other items not covered by the basic hospital insurance. After you pay for the first $135, Medicare pays 80% of approved** charges for these services each year.
Home health services — unlimited visits under an approved plan. insurance pays approved cost of covered services with no deductible. (Medicare does not pay for home health services if you are in a skilled nursing facility).
Physician's and surgeons' services, whether services are received at home, in a hospital or elsewhere. Also some limited services of chiropractors are covered.
Outpatient hospital services, including x-rays and tests, your physicians' and hospital staff physicians' services, medical supplies and services.
Other medical and health services, including tests, surgical dressings, rental and purchase of medical equipment, certain colostomy care supplies, outpatient dialysis treatments, outpatient physical therapy and speech pathology.
** Your physician's bill may be higher than the "approved charge" set by Medicare. See "The Medicare Handbook" or your local SSA office for an explanation of the difference.
Important Services Not Covered by Either Plan
Custodial care
— for personal needs
— doesn't require professional skills or training
Routine physical checkups, hearing exams, dental care
Eyeglasses and eye exams for prescribing, fitting or changing eyeglasses
Hearing aids
Dentures
Orthopaedic shoes
— unless they're part of leg braces and included in the orthopedist's charge
Private duty nurse
Personal services — in your hospital or skilled nursing facility room (telephone, TV, etc.)
Non-replacement fees charged for the first three pints of blood or packed red cells
— per benefit period (hospital insurance)
— per calendar year (medical insurance)
Acupuncture
Drugs
Under HOSPITAL PLAN
Drugs are covered if furnished to patient in hospitals or skilled nursing facility in a Part A stay.
Under MEDICAL PLAN
Drugs which cannot be self-administered are covered if administered as part of a physician's professional services or as part of outpatient hospital services.
Medicare Part B - Prescription Drug Coverage
Under MEDICAL PLAN
Medicare Part D provides outpatient prescripton drug coverage for Medicare beneficiaries who enroll. Once the Medicare Part A stay in a skilled nursing facility is complete, if further custodial care is needed, Part D would cover necessary drugs if you are enrolled in the program.
Some Questions and Answers:
What about after 100 Days?
Medicare Part A cannot pay for skilled nursing facility services after the 100th day in a benefit period. In this situation, if you cannot afford to pay for the care, you may want to ask the people in your local public assistance office about the possibility of help under the state's medical assistance plan.
What about facilities that do not provide skilled nursing care?
Many facilities provide only room and board with limited medical services. Even though this care is quite important and is needed by many people, Medicare cannot pay for it.
Your certified skilled nursing facility, in cooperation with your physician and your health officials, is part of a health program dedicated to giving you the best possible medical care.
If you have any questions or lose your Medicare card, get in touch with your local Social Security office.