A Little Known Reason Why Medicare Will Deny Coverage For Your Nursing Home Stay
There are few things more wrinkle-inducing than the stress of any unexpected bill, let alone a $6000-8000 nursing home expense left uninsured by Medicare.
But it happens everyday. If you receive only custodial care at the nursing home, Medicare will not cover you. (Read this blog for a few answers.) And even if you are receiving skilled nursing care, there is still a chance you won’t be insured.
Here’s the reason: Many people don’t receive 3 days of inpatient care before moving onto the nursing home. This is a requirement for coverage!
Check Your Status!
What really throws people for a loop is that not all hospital stays qualify as the required inpatient care. So even if you stay a week in the hospital’s luxurious half-room with a moaning mystery patient on the other side of the curtain, that doesn’t mean you satisfied the requirement (even though you definitely earned it, in my opinion).
Why, you ask?
It has to do with your official status. Some people are formally checked-in, but others are filed under “observation status”. In other words, they are not receiving any specific treatment but are rather checked in for the purpose of evaluation, testing, and monitoring. In almost all respects, they receive similar care to those who are formally checked in, but these patients are billed and covered like they are receiving outpatient services. They don’t fulfill the 3-day inpatient requirement and—when they move on to a skilled nursing facility like a nursing home—they are denied coverage when they need it most.
Sounds a bit unfair, right? I agree wholeheartedly. Luckily, the government is aware of the issue and is taking steps to resolve it.
Baby Steps
One of these small steps occurred in August of 2015 when Obama signed the Notice of Observation Treatment and Implication for Care Eligibility Act. I know—legislators have a knack for snappy titles. But in all seriousness: What the article lacks in creativity, it makes up for in functionality. This Act requires hospitals to alert you of your observation status and how it will affect your Medicare coverage in both writing and in person.
Potential Strides
The Notice Act doesn’t solve the whole issue, of course. It would be better to just allow all hospital stays to count toward the 3-day inpatient requirement. The good news is—yet again—politicians are working toward this.
But until then, be aware and ask about your status. It pays to be educated. And it can save you an arm and a leg to know what others don’t and what hospitals neglect to tell you.
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About the Author
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