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 Medicaid vs. Medicare

Nursing Home Costs and Ways to Pay

 Medicare vs. Medicaid - Who Covers Nursing Home Costs?

Additional Lifestyle Articles

The cost of a nursing home stay can overwhelm seniors and their family members very quickly. According to the 2020 Genworth Cost of Care Survey, the median cost of a semi-private room in a nursing home is $7,756 per month. Fortunately, Medicare, Medicaid or both programs may be used to cover nursing home expenses, depending on the circumstances.

The most significant difference between Medicare and Medicaid in the realm of long-term care planning, however, is that Medicaid covers nursing home care, while Medicare, for the most part, does not. Medicare Part A covers only up to 100 days of care in a "skilled nursing" facility per spell of illness.

One of the questions asked often is "Who covers nursing home costs? Medicare or Medicaid"? Because staying in a nursing home may be covered by either Medicare or Medicaid, it can be confusing to determine which program will over your family member's length of stay.

Does Medicare Cover Skilled Nursing?

Medicare generally doesn't cover long-term care stays in a nursing home. Even if Medicare doesn't cover your nursing home care, you'll still need Medicare for hospital care, doctor services, and medical supplies while you're in the nursing home. Medicare covers 100 percent of the costs for the first 20 days.

Beginning on day 21 of the nursing home stay, there is a significant co-payment ($176 a day in 2020). This copayment may be covered by a Medigap (supplemental) policy. After 100 days are up, you are responsible for all costs. Most people who enter nursing homes start by paying for their care out-of-pocket.

Many people believe that Medicare covers nursing home stays. In fact Medicare's coverage of nursing home care is quite limited. Medicare covers up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered.

Being Discharge From Hospital

When you are ready to leave the hospital, but are not yet well enough to return home, your doctor may determine that you need to go to a skilled nursing facility for a time, if you meet the Medicare requirement of a three-day inpatient hospital stay. The hospital staff works with you and your loved ones to find a skilled nursing facility of your choice that accepts Medicare and provides the services you need.

Skilled nursing facilities provide care and services from the skilled staff that has specific expertise to treat patients and help them recover to their best possible level of well-being.
Medicare indicates that it covers skilled nursing care at a skilled nursing facility for a limited time period. You have to first meet all eligibility requirements to receive coverage for care provided at a skilled nursing facility.

Eligibility requirements include that you have Medicare Part A with days left in your benefit period and have a qualifying hospital stay. Your doctor has to have made the decision that you need skilled care provided by or directed by skilled nursing staff or therapy professionals at the skilled nursing facility. You receive your skilled nursing care at a Medicare-certified facility.

Skilled nursing care and services covered by your Original Medicare include a semi-private room, meals, medications, medical supplies and equipment, medical social services, dietary counseling, skilled nursing care and specific therapies to meet your goals.

Examples of covered therapies include physical therapy, occupational therapy, speech-language pathology services. This is not a complete list of Medicare-covered care and services.

Does Medicaid Cover Skilled Nursing?

Although Medicaid is a U.S. Federal Government Program, Medicaid gives a great deal of opportunity for individual states to make decisions on coverage and benefits for Medicaid recipients. This is true of all groups, including seniors, receiving Medicaid or who are dually eligible for both Medicare and Medicaid.

Medicaid covers skilled nursing care at Medicaid-certified skilled nursing facilities. Eligible Medicaid recipients have to meet criteria for nursing facility care in their own state, yet the individual states must also abide by federal law and regulations when setting their skilled nursing care requirements and guidelines.

About Texas Medicaid Planning and Eligibility

Medicaid covers skilled nursing facility care and services such as nursing services, rehabilitative services, pharmaceutical services, medical social services, meals and other care.

Medicaid reveals that it provides coverage for skilled nursing care that allows each eligible recipient the opportunity to "Attain or maintain the highest practicable physical, mental, and psychosocial well-being."

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