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Official CMS Booklet of Medicare Coverage For Skilled Nursing Care

Placing a loved one in a nursing home is not easy—mentally, emotionally, or financially. On the finances front, there is generally only three ways that most long-term care can be paid for: (1) out of one’s pocket; (2) through use of long-term care insurance; or (3) with Medicare and Medicaid assistance. The monthly costs for these services are usually immensely high. It is rare for families to be able to afford any extended stay on their own. For the same reasons, insurance for this care is always quite expensive-few families are able to swing the premium payments. That is why our Chicago nursing home lawyers are very aware of the fact that federal support in the form of Medicare and Medicaid are the main payers of this long-term care. This is how requirements, inspections, and demands made by the Centers for Medicare and Medicaid Services (CMS) must be heeded by long-term care facilities. Otherwise CMS threatens to refuse to send patients to the home. While many facilities could technically still operate without CMS, in reality, loosing access to CMS residents means that the facility is not able to function.

The CMS involvement is one way that nursing home neglect and abuse is sought to be kept in check, because the federal programs will not pay for care that is inept. However, the federal involvement also means that residents and their families are forced to deal with the often confusing bureaucratic mess that is the Medicare and Medicaid programs. For many families who are already emotionally wrought over the idea of having their loved one live in an assisted living facility, figuring out what their loved one qualifies for and how to get the help can seem daunting.

At an introductory level, there are clear differences between the type of nursing home care that Medicare will cover as opposed to Medicaid. In general, Medicare will provide only short-term stays for rehabilitation following hospitalization. Conversely, Medicaid will help pay for longer stays. Yet, the requirements to qualify for each program are not the same. It is very helpful for families going through this process to speak directly with experts in the area to learn what hoops they have to jump through to qualify for what they need.

Many intrepid readers might wish to learn more on their own. In that case, a good starting point is this CMS guide called, “Medicare Coverage of Skilled Nursing Facility Care.” The booklet acts as a primer explaining exactly what skilled care is provided by Medicare and what rights and protections are guaranteed to those using the services. In addition, the booklet provides a very helpful list of references indicating where families can turn to for more help if they are confused.

Medicare does not cover what is commonly referred to as purely “custodial care.” This includes help with daily activities-like eating, bathing, and dressing. If that sort of day-to-day assistance is what is required, then Medicaid is the program that provides the services instead. Instead Medicare only covers skilled care for a maximum of 100 days so long as certain requirements are met. For the first 20 days, Medicare will cover the costs entirely. Any stay between 20 and 100 days will require a copayment. Even then, the care is only covered so long as a set of requirements are met. Take a look at the booklet for more detailed instructions, but those requirements include things like having had a qualifying hospital stay, having left the hospital within the “benefits period,” the doctor has ordered the skilled care, the care you need is daily, and similar factors
Conveniently, the booklet also shares information about how to choose an appropriate skilled nursing facility. Our nursing home lawyers know that many have heard the horror stories about inadequate care at many of these facilities. Avoiding nursing home abuse and neglect is always a concern, and the guide helps direct families in the best ways to go about choosing an ideal temporary home.

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