When Does Medicare Pay For Nursing Home Care?

Health Care Reform Bill Facts - When Does Medicare Pay For Nursing Home Care?

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One of the most tasteless phone calls I receive in the office is when someone's mum or father is admitted to the hospital. In this time of crisis, answers are not easy to come by.

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Health Care Reform Bill Facts

How does their health insurance work? What does Medicare pay for? Once the parent is discharged, what happens, where do they go, how is it paid for, what are our options? What do we do if mom or dad is going to have to go to a nursing home? How do we pay for it?

This obscuring is imaginable as the senior health care ideas can be a very confusing and amazing process. The first thing to do is to understand the basis for today's system.

In 1983, Congress created the Prospective cost System. This is important because when a man 65 or older is admitted to a hospital, he is assigned only one of 473 Diagnostic related Groups (Drg's). This is important because Medicare compensates the hospital a flat dollar estimate for the Drg assigned to the patient.

Let me give you an example. Say that my father is admitted to the hospital with lung problems and the Drg is four days. If my father is discharged in three days, then the hospital makes one day of profit. If my father is discharged in five days then the hospital loses money and cannot bill the sick person for the one extra day.

Back in the good old days, I remember when my grandfather was in the hospital and the nurse asked him if he felt well enough to go home because if he didn't, he could stay a few extra days until he felt better.

Today, it is all about the money. Once a sick person is no longer getting great or worse, in other words, is deemed to be "stable", then the sick person is discharged either to home or a Medicare certified nursing home or rehab facility.

In order for Medicare to pay for rehab care the sick person must have been in the hospital for three consecutive days (72 hours). Then, no later than thirty days after discharge from the hospital, be admitted to a Medicare certified nursing facility.

If these criteria are met, then for 2010, day's one straight through twenty in the rehab facility are paid for 100% by Medicare. For days twenty one straight through one hundred, your co pay is for this year is 7.00 per day.

From day 101 and beyond, regardless of your condition, you are responsible for all of the facility costs.

Keep in mind, that in order for this repayment schedule to happen, you must either be getting great or getting worse. Like the hospital, once you are deemed to be stable, you come off the Medicare repayment schedule and must pay for all costs.

In California, most patients will come off of Medicare repayment around week three and must begin secret paying from this point forward. The business office will recommend you when this is imaginable to take place.

If the facility has long-term care beds, then the sick person may be able to stay in the same facility. But if the facility is strictly short-term care or rehab, then the sick person must find someone else facility or go home.

How does the patient's health insurance fit into this? It all depends on what type of plan that the senior sick person is on. Is it a Medicare supplement plan or Ppo, or is it a Medicare advantage plan like an Hmo?

Medicare supplement insurance, also called Medigap, is secret health insurance designed to supplement Medicare. A superior is paid for this coverage which is age rated.

There are twelve standardized Medigap plans, A straight through L. In most states, you can go to any physician or hospital that accepts Medicare without pre-authorization. Under plans C straight through J, days one straight through twenty are completely paid for by Medicare. For days twenty one straight through one hundred, the Medicare co-pay for 2010 is 7.00 which is covered by the Medigap policy. From day one hundred one and beyond, the sick person is responsible for the full cost.

For Medicare advantage plans such as an Hmo like acquire Horizons, Scan and Kaiser, the patients may have a co-pay from day eleven of 0. It is best check the benefits booklet or call the buyer assistance department.

If man goes to a facility without going to the hospital first, then you must secret pay from day one.

Once the sick person comes off Medicare reimbursement, if qualified, Medi-Cal will help to pay for the nursing home costs. If going to the facility directly from home, then, if qualified, Medi-Cal may help to pay for the nursing home costs from day one.

Please consult with a Medi-Cal devotee for more facts and the exact procedures.

Copyright 2010 by Karl Kim

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