What happens if a patient needs to stay in skilled nursing care on Medicare?

A person can't stay in a facility past the time it's covered by Medicare unless the person can afford to pay out of pocket. Most people can't afford this. At some point the person or family is approached by the facility's financial people and/or social worker if it's been assessed the person needs more time there than Medicare will pay for. The family will have to apply for Medicaid on behalf of their loved one. As long as the family is actively in the process of applying for Medicaid the person can stay in the facility. Once Medicaid is approved they will back-pay the facility and continue to pay for the person's stay in the facility.

Medicare will only pay for the first three weeks (I think) of a stay after a hospitalization. After that they pay part of the cost for up to 100 days (I think). The patient has a copay of $167/day for days 21-100. After that, the patient has to pay or be determined eligible for Medicaid. If you think a family member is in a nursing home permanently, you should start the Medicaid application as soon as possible. Patients can stay in nursing homes as "Medicaid pending" under some circumstances. There should be a social worker at the nursing home who can help you with the application.

Of course, this assumes the patient is financially eligible for Medicaid. If the patient has funds, those funds need to be spent for their care before Medicaid will kick in.

Private pay.

If your loved one will run out of money, you apply for Medicaid, which requires that you be both medically and financially at need.

If there is a spouse who is remaining in the home, you really need to get an eldercare attorney involved in the application.

I reported this on other threads, but I was very surprised to find out what I did this week. My dad is a veteran, but we were told by many at the VA that he can stay free at a VA contracted private nursing home IF he has at least 70% service related disability which my dad does not (luckily). And that is fair I don't think we or any one expect things for free just to get them for free. But this week found out that disability is not the only condition. If you are categorized in hospice, which my dad is, you can also stay free at a private SNF which has VA contracts. A lot of our elderly parents are veterans, and a lot of them declared to be in hospice.

The patient is responsible for the cost.

Patient's who have no funds, or after they have used their funds, can apply for Medicaid. If they are qualified medically and financially, Medicaid pays. Note that not every SNF accepts Medicaid payments and if that is the case, the patient has to find one that does. For Nursing Homes, most do accept Medicaid.

Start your Medicaid app now. It took me almost 6 months to have my husband accepted. While answering for 5 years of financial history I was charged $3,300/ month before he was moved into nursing care. In some states Residential Care is nothing more than warehousing.They wouldn't allow me to set up a payment plan. I questioned Medicaid and they said that the skilled nursing home can charge what ever they want until he was accepted into Medicaid. I spent over $20,000 of our savings for that care. I feel for you because it may help to hire an attorney. Check their back round in Elder Care and Medicaid apps. You may need to become their legal guardian if you don't have a POA (power of attorney).
I know how unpleasant this process is. I only wanted to make sure he was safe, yet when you don't understand the process you can easily be confused when talking to people who no more than you do.
Very best of luck.

Of course up to the time your loved one runs out of money and get Medicaid, they pay from their own pocket. I don't know if the person is a veteran, but if so, there may be some benefits there.

Carla didn’t mention that the patient has to show progress w physical therapy. My mother w dementia refused to cooperate w physical therapy so I had to private pay..at a rate of $375/day. My mother would sit in shit all day till they finally got around to taking her to bathroom. Since she needed lift machine they required 2 people...long story short she’s been home for 13 months after being in SNF for 10 months. Medicaid home care still not kick in yet.

If one doesn't improve under physical therapy, it can be stopped--this happened to my father when the therapist said "he is simply incapable of doing anything". My mother had physical therapy but gave up on it and soon became bedridden because she had too much pain in one leg (both of which contain metal rods installed during surgery after the femur in each broke due to osteoporosis). They both had to go back to private pay. (I didn't have the heart to tell my mother that her quitting physical therapy effectively cost her ca. $16K that Medicare otherwise would have picked up.) How ever, this nursing home "only" charges $210 per day (and $200 back then); I feel sorry for people who live in states in which it is much more expensive. My father only lived about 7 months after that while my mother is still alive at 93 after being in this home for 4 1/2 years.

If SN care is needed, the progress in therapy should not be used as a reason to stop Medicare payments. See Jimmo vs. Sebelius below. You will have to fight to get the facility to go along with this, but when you show that you have done your research, they will cave.

Per Medicare @ www.cms.gov/Center/Special-Topic/Jimmo-Center.html
Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.

Also
Jimmo Settlement Agreement approved by the court on January 24, 2013 [PDF, 134KB]

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-Settlement-Agreement.pdf

and

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/jimmo_fact_sheet2_022014_final.pdf

and

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf