Knowledge is Power!

Ask MyCaseManager Monday- Nursing Home-How long will my insurance pay?

Dear MyCaseManager,

My father was just admitted into a nursing home  for physical therapy.  I am so glad that he is finally in a facility.  He has been living alone and I am really worried about him.  How long can he stay at the nursing home and how long will his insurance pay for this?

This is a common question. First, we will need to understand what is paid for by Medicare/health insurance.  Medicare and most private insurance pays for “skilled care” at a nursing home, or skilled nursing facility as they are referred to in the medical community.  Medicare’s (and other medical insurance) definition includes care needs that require a licensed nurse or rehab professional at least daily.  Skilled professionals include, RNs, LVNs, Physical Therapists, Occupational Therapists and Speech Therapists.  Functions to assist with activity of daily living like feeding, bathing, dressing, even administration of oral medications, are not considered skilled need.  They are referred to as custodial care and are not paid for by medicare or any other medical insurance, with the exception of medicaid, unless there is also a skilled need.   Some long term care insurance policies cover custodial care in a skilled nursing facility.  If you have this type of policy you should check with your insurer about this.

From your information, it sounds like because your dad was specifically admitted for Physical Therapy, he is probably under the skilled benefit.  The facility therapists will continue to work with your dad until he meets his treatment goals or he plateaus in his progress.  Most insurance plans have a 100 day per year benefit for Skilled Nursing.  However, it is a rarity that a patient will need 100 days of service at one time to meet the treatment goal or plateau criteria.  Usually this is done within a matter of days to weeks.  The facility should meet with the patient and family soon after admission to discuss a discharge plan.  In your case, if you and your father are interested in him staying at the skilled nursing facility after the skilled benefit runs out, you will need to discuss other financial arrangements with the facility, such as a long term care insurance policy, medicaid or a private pay agreement.  It is important to address these issues early after admission so that you are not in a panic when your father is no longer eligible for his skilled benefit.  If you and he decide that a continued stay is not feasible, you should discuss other options with the discharge planner/social worker at the facility.  Other options for care may include a home caregiver, Adult Daycare Programs, local community Senior Center Services, etc.

Please also check out this great publication by the Oregon Health Care Association that gives more detailed information about the Skilled Nursing Facility medicare benefit.  Again, most private insurances also go by the same guidelines as established by medicare.

Knowledge is Power!


September 20, 2010 - Posted by | Ask MyCaseManager Mondays!, Nursing Homes | , , , ,

1 Comment »

  1. These are so interesting to read Lorrie. It is quite a maze to manuever when you are not feeling your best. I am glad there are ppl like you out there to help guide the way and keep us updated on what we should know.
    Thank you!!!

    Comment by Kerri Lydell | October 10, 2010 | Reply

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