Just as Americans have struggled with how to pay for long-term care for senior citizens who require daily, skilled nursing, so has our government. For a long time, people without independent means to pay for nursing home care were forced to rely on Medicaid, the federal insurance plan for the poor. The rules for Medicaid eligibility are strict, however, so it wasn’t enough that people couldn’t afford expensive long-term care; they needed to be poor enough overall to qualify.
What this meant in practice was that many couples were forced to spend down all their assets if one spouse had to move into a nursing home. Through advance planning, some people were able to shield the healthy spouse’s share of the assets, but other people just had to live with the fact that a nursing home for one spouse would impoverish the other.
A large chunk of estate planning and elder law was dedicated to dealing with this reality, so it’s a familiar theme in law offices. The good news is that it hasn’t been true since 2013, when a court ruled that Medicare — the general insurance program for retirees — should be paying some of these costs.
Medicare pays for some medically necessary skilled nursing care following hospitalization
Under the old rules, it was tough to qualify for Medicare coverage of skilled nursing care. The rule was that Medicare would pay for medically necessary skilled nursing care, but only to the point where the patient’s condition was no longer expected to improve. In other words, even if the treatment was still necessary to maintain your condition or keep it from deteriorating, Medicare was off the hook.
The 2013 court ruling changed that. Now, Medicare is required to keep paying as long as the treatment is medically necessary.
That doesn’t mean Medicare will necessarily pay for residential nursing home treatment. The ruling only applied to the treatment, monitoring and intensive rehabilitation skilled nursing facilities provide following an acute illness or injury or an inpatient surgical procedure. Those services are for a specific medical event and generally only last a few days or weeks.
It only covers treatment following at least three full days of hospitalization, and it only lasts 100 days. Medicare (via supplemental insurance, if available) only covers the full cost for the first 20 days; after that, there’s a daily co-pay.