Business Office Coordinator
Arlington Court Skilled Nursing & Rehab Center
Understanding Medicare Benefits
When a resident has Medicare, it is not always explained right to them what their benefits are.
For Medicare to cover the stay at a skilled nursing facility, the patient will need to be admitted for 3 nights at a hospital. Medicare will then cover the first 20 days at 100%. Starting on day 21, there is a $167.50 copay per day until day 100. Some patients are fortunate enough to have a secondary that will pick up the coinsurance. If a patient uses all 100 days of their Medicare benefit, they will need to have a 60 day break before their Medicare days resets.
A 60 day break consists of a break from skilled services. This includes going back into the hospital. If a patient only goes to the emergency room or is sitting in observation, that does not count but if a patient is admitted that counts, and the count for the 60 day break starts over. After a 60 day break has occurred and a patient needs a new 3 night stay at a hospital.
If a patient has not used all their days and is discharged to the community and then needs to come back into the skilled nursing facility within 30 days of being discharged, the patient can come back without a 3 night hospital stay and will start on whatever day that they discharged on for their Medicare days. If they need to come back after 30 days, they will need to have another 3 night hospital stay and also start on whatever day that they discharged on for their Medicare days.
Medicare pays for skilled services in a skilled nursing facility. If a patient switches to hospice within a nursing facility, Medicare will pay for the hospice benefit but will not pay for room and board at the nursing facility. Medicare will also pay for outpatient therapy services at home or at an outpatient clinic, but there is a small copay unless the patient has a secondary insurance to help cover the copay.
Medicare is an earned benefit that can be very beneficial to patients when they are using it to their full potential.