Many are surprised to learn that Medicare does NOT pay for a nursing home in most situations. Medicaid, not Medicare is the primary payer for most Georgia nursing home care. Medicare may cover the cost of a skilled nursing facility only if it follows a hospital inpatient stay. How can you get Medicare to cover the cost of nursing home care?
Did you know the federal government wants Georgia to repay over $100 million in federal money used to pay for nursing home admissions? How will this impact retirees who may need nursing care? How does this impact the Georgia Medicaid estate recovery program?
Long term care insurance, along with adequate life insurance and a good Medicare supplement plan form the three legs of insurance estate planning. Georgia Medicare Plans can help you compare Medicare supplement costs from over 170 different plans. Shop and compare. Instant GA Medigap rates.
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Getting Medicare to pay for your nursing home stay
Most people just assume nursing homes are covered by Medicare.
You should never assume.
Medicare does not pay the largest part of long-term care services or personal care—such as help with bathing, or for supervision often called custodial care. Medicare will help pay for a short stay in a skilled nursing facility, for hospice care, or for home health care if you meet the following conditions:
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You have had a recent prior hospital stay of at least three days
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You are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay
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You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy
The 3 day rule (above) has been amplified and restated
New rules published by the Centers for Medicare & Medicaid Services (CMS) in August 2013, which became effective October 1, 2013, do NOT change the statutory requirement that a patient spend at least THREE consecutive days in a hospital as an inpatient in order to qualify for Medicare coverage of a subsequent stay in a skilled nursing facility (SNF).[1] The two-midnight standard set out in the new regulations is simply a tool for physicians to apply in making inpatient admission decisions. If a physician believes a patient will require at least two midnights in the hospital, the physician should admit the patient to inpatient status, but patients continue to need three midnights as inpatients to qualify for Medicare coverage in a SNF.
Admitted as an inpatient or for observation?
Medicare will consider paying your bill for a SNF (Skilled Nursing Facility) only if you have had 3 or more consecutive midnight’s in an acute care facility as an INPATIENT.
Too often patients are admitted to the hospital for OBSERVATION. Once their condition stabilizes they may be discharged to a nursing home for extended care. The difference in your out of pocket costs when admitted for observation vs. as an inpatient are staggering.
Consider what happened to Rosalie Winkworth during and following her hospital stay.
So when (Rosalie) spent four days in the hospital there was no reason to think that she was anything other than an inpatient. When a social worker told her that her mother was on observation status, it really didn’t register. “I thought she was being watched,” says (Rosalie’s daughter Donna Maxcy). “Observed.”
After Winkworkth’s discharge, her doctors said she needed to go to a nursing home. But since the hospital considered her an observation patient, not an inpatient, the family had to pick up the bill. – NPR
Outpatient hospitals stays, including admitted for observation, are covered under Medicare Part B. Your out of pocket cost with Medigap plan F would be $0 for the balance of Medicare approved Part B expenses.
Most of our clients have Medicare supplement plan G or N because of the greater value. In that case the patient is responsible for the Medicare Part B deductible ($147 in 2015) unless the deductible has been previously satisfied.
Our clients average saving over $500 per year in Medicare supplement plan costs. How much can you save? Click to shop and compare GA Medigap rates instantly.
Washington wants their money back
Washington called. They want their $100 million back.
Federal officials want Georgia Medicaid to return more than $100 million in payments made to nursing homes. The feds say these payments were not permitted under the program’s regulations.
The payments were made in fiscal years 2010 and 2011. – Georgia Health News
Sounds to me like DC is running out of money. Perhaps they wasted too much of OUR money and now want as much of it back as possible.
What’s good for the goose is also good for the gander. Georgia wants their money back too.
A federal judge ruled in February that Georgia should receive a refund of $90 million of Medicaid funds it mistakenly returned to the federal government, even though the state made its claim for the money after the two-year window to do so had expired.
As it stands now, Georgia is out $90 million in money they sent back to Washington but (they feel) should not have been repaid, plus DC says they owe another $100 million.
A million here, a million there, before long you are talking about a lot of money.
With all these Medicaid dollars flowing back and forth from DC to Georgia, how does this impact you and me?
For one thing you can expect Georgia to step up their Medicaid Estate Recovery Program. Unlike Washington, we can’t print money here and our Constitution REQUIRES a balanced budget.
Medicare supplement plan cost
If you meet the requirements where Medicare will pay for your nursing home stay it’s good to know what portion is paid by Medicare and what is your responsibility. The Medicare Coverage of Skilled Nursing Facility Care is a good place to start. Their 50 page booklet covers almost everything you need to know about Medicare and nursing homes.
Medicare supplement plans F, G and N will pay 100% of approved Medicare nursing home claims.
If you currently have plan F you are probably paying too much. You might also want to compare benefits and prices for Medicare supplement plans G and N.
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