Medicare does not include provisions for prolonged custodial care like that found in assisted living facilities, but there are specific instances when stays in a nursing home may be covered under Medicare.
Medicare provides an array of healthcare services to those covered, regardless of housing arrangements. Yet, akin to the majority of health insurance policies, Medicare does not fund the continual care expenses associated with an assisted living environment or daily custodial care needs.
In particular situations, if an individual requires a limited duration of stay for inpatient services in a skilled nursing facility and the services are beyond mere custodial or persistent care, Medicare might provide coverage.
When does Medicare cover care in a skilled nursing facility?
Original Medicare may finance a part of the costs for a maximum of 100 days per benefit period in a skilled nursing facility, given that a physician has confirmed the necessity for specific medical services post a qualifying admission to a hospital. Assisted living establishments differ as they do not offer the extensive medical attention found in skilled nursing.
For a hospital confinement to be deemed “qualifying,” a formal hospital admission is mandatory for at least three consecutive days. Any time spent under observation or as an outpatient prior to admittance does not contribute to the qualifying three days.
The skilled nursing facility must hold a Medicare certification. Furthermore, a physician must validate the necessity for the facility’s care. The treatment provided at the facility must link to the condition that initially led to the hospital admission or must be related to a complication arising from the hospital stay, such as an infection acquired therein. The services rendered by the nursing facility also must be deemed clinically essential.
The initiation of care in the skilled nursing facility should typically occur within 30 days following hospital discharge. In the event of re-entering a skilled nursing care facility within 30 days after cessation of care or exiting the facility, there’s no need for an additional 3-day qualifying hospital stay.
