October 21, 2019










When Does Medicare Cover Nursing Home Costs?

When and how long Medicare covers nursing home costs will vary, but understanding how your benefits work and when they kick in is critical when you require nursing home care.

Most seniors will reach a point where they need nursing home or long-term care. Sometimes, it is only after an illness or accident, while other times the situation is permanent. If you are receiving Medicare or you are eligible to apply, you may assume that your costs are 100 percent covered with Medicare benefits.

This assumption, unfortunately, is incorrect.

Medicare does not cover a lot of traditional healthcare costs, and nursing homes are one of the costs.

However, when your nursing home or skilled nursing facility care is medically necessary, then you may receive some coverage.

When Does Medicare Cover Nursing Home Stays for Plainview Residents?

Medicare’s coverage of a long-term nursing facility is incredibly limited. Under the traditional Medicare plan, you will only receive limited care coverage for skilled nursing home facilities. The care only applies while it is a medical necessity. And to prove it is medically necessary, your physician would need to fill out the appropriate forms indicating such.

Up to 100 Days of Skilled Nursing Care with Medicare

Medicare Part A provides up to 100 days of skilled nursing care after an illness or injury. However, the requirements for utilizing this coverage are incredibly strict, including:

  1. Enter a Nursing Home within 30 Days of a Hospital Admission – For Medicare coverage, you must have recently been in the hospital and your admission into the nursing home cannot be more than 30 days after the admission. Likewise, your hospitalization must last a minimum of three days.
  2. Similar Care as the Hospital – The care you receive at the nursing home must be identical to the care you would have received if you were staying in the hospital; therefore, it must be required to treat a medical condition.
  3. Skilled Nursing Care Is Required – You must need an experienced level of nursing care, and the facility must have skilled registered nurses that treat you in-house. A physician must have placed orders, and a physician must supervise you during your treatment period. Likewise, a licensed practical nurse or registered nurse must carry out those orders and do so daily to qualify. Not many nursing homes have this level of skilled nursing care.

Once the nursing home reports to Medicare that you no longer need the skilled nursing home level of care, Medicare will stop payments.

What Other Options Do You Have to Pay for Nursing Home Coverage?

Nursing home costs are on the rise, and while you might not have Medicare to pay for your nursing home stay, you are not without options either.

Long-term care insurance is another option, but it does have a hefty premium. That being said, it will make up for the costs of nursing home stays, which will exceed the premium for 24-7 nursing home care.

Medicaid Is Another Option

One option that you might not have thought about is Medicaid. Medicaid works as long as you do not have many assets, and your income is relatively low (to none, if you are retired). Your Social Security income and pension income does fall under consideration when applying for Medicaid coverage.

Under a Medicaid plan, you can receive coverage for a long-term nursing home care or assisted living, but the rules depend on multiple factors. Federal law requires that all states carry a Medicaid program, but each state has rules that they use to govern who qualifies and what they pay for using these Medicaid benefits.

Medicaid in New York will pay for nursing homes and assisted living care, which is a relief for those facing the outrageous costs of nursing homes today. However, you must meet the income limits and be either 65 years and older, disabled, or blind to receive Medicaid coverage for your nursing home.

Also, your income cannot exceed the state threshold, which was $842 or less for singles and $1,233 per month for couples as of 2018.

How an Estate Planning Attorney Can Help

Medicaid is a joint run program by the federal government and the state of New York. To qualify for nursing home care, you first must qualify for Medicaid coverage.

Certain items that the Department of Social Services considers when qualifying applicants for Medicaid coverage in New York include:

  • Need of Care: Do you have a financial need and medical necessity that qualifies you for the level of care you are seeking?
  • Your Income: Naturally, your income, as well as your spouse’s income (when applicable) is considered. You cannot exceed the state’s maximum threshold. All income sources are considered in New York, including your distributions from retirement funds, pension payments, investments, rental properties, and Social Security benefits.
  • Your Resources: You might not have a large amount of money as income, but you may have considerable assets. When your assets are high enough, the state will deny your Medicaid application. Assets include everything from the value of your home to investments to insurance plans.

While the process of qualifying for Medicaid is complicated, an estate planning attorney in the state can help you by going over your options, assessing your eligibility, and working to determine how to protect your assets so that you can qualify for the care you need without having to liquidate your family’s estate in the process.

Speak with an Estate Planning Attorney Today

If you are worried about paying for nursing home expenses in the future, or if you would like to have a professional help you draft an estate plan that protects you when the time for nursing home care comes around, speak with Andrew M. Lamkin, P.C., today.

He can assist you with protecting your assets, looking over your long-term care options, and ensuring you qualify for Medicaid later.

Schedule a free case consultation now by calling us or requesting more information online.