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Nursing Homes Explained: What They Are, What to Expect, How to Pay For One & How to Find One

What They Are

Nursing homes or convalescent homes are also known as skilled nursing facilities, or SNFs (pronounced "sniffs"). SNFs are live-in facilities that provide medical treatment prescribed by a physician. These nursing care facilities cater to several types of patients: some patients require short-term rehab while recovering from surgery; others require long-term nursing and medical supervision. In addition, some SNFs offer specialized care programs for Alzheimer's or other illnesses, or short-term respite care for frail or disabled persons when a family member requires a rest from providing care in the home.

What to Expect

SNFs provide twenty-four hour nursing care; rehabilitation services such as physical, speech and occupational therapy; assistance with personal care activities such as eating, walking, bathing and using the toilet; coordinated management of patient care; social services; and activities.

Paying for Skilled Nursing Facilities

The primary ways to pay for skilled nursing facility care are Medicare, Medigap and Managed Care, Medicaid, Long-term care insurance policies (LTCI), Veterans Benefits or private payment. Most skilled nursing care at a facility is covered initially by Medicare. After Medicare coverage stops, your options are LTCI, Medicaid, private payment or a combination thereof. Read a detailed description of all types of reimbursements.

Medicare

What is Covered

• First 20 days in a Medicare-approved skilled nursing facility
• Days 21-100: Medicare pays for all covered services except for a daily coinsurance amount which adjusts annually; 2007 coinsurance is $124/day, 2008 coinsurance is $128/day
• Doctors' visits
• Nursing care
• Semiprivate room rates
• All meals (including special diets)
• Physical, occupational and speech therapies
• Lab and X-ray services
• Prosthetic devices
• Prescription drugs
• Some medical supplies and equipment

Conditions and Limitations

There are strict limitations to Medicare coverage in skilled nursing facilities.

• Beneficiary must be in hospital for 3 consecutive days, not counting day of discharge.
• Must be admitted to skilled nursing facility within 30 days of hospital discharge
• Services must be related to condition that was treated in hospital
• Must require daily skilled nursing or rehabilitation services
• Must be determined that services can only be provided on an inpatient basis
• Doctor must specify need for daily skilled care services; and
• Doctor must re-certify need at day 5 and day 14 after admission, and every 30 days thereafter
• Medicare must review and approve continued need for skilled care services
• Skilled nursing facility stay must be 100 days or less; and
• Medicare must approve the length of stay (100 days are not automatically granted)

Medigap

What It Covers

Eight of the ten basic Medigap policies (Medigap Plans A-J) completely cover days 21-100 skilled nursing coinsurance; Medigap Plans K-L cover a portion. Three states have their own Medigap plans. In Massachusetts, the core plan does not cover skilled nursing facility coinsurance, but a supplemental plan does. Skilled nursing facility coverage is provided in Minnesota both with the basic and extended basic plan and in Wisconsin with the basic plan.

Managed Care

What It Covers

Managed Care policies cover everything that Medicare covers (see Medicare). Sometimes there is a co-payment, however, for days 21-100, that is usually about half the cost. In addition, no prior hospital stay is required.

Conditions and Limitations

• Skilled nursing facility must be Medicare-certified; and
• Resident must get authorization from the insurance company for services

Medicaid

Note: Medicaid recipients must give a portion of any social security income towards payment of skilled nursing facility services.

What It Covers

• All costs of skilled nursing services and medical equipment that a doctor deems necessary (usually an individual will need assistance with at least two activities of daily living)
• To hold a bed for a finite amount of time, usually a one- to two-week period, if a resident requires temporary hospital care
• For leaves of absence of up to 18 days per year for visits with family or friends

LTCI

What It Covers

Facility Only and Comprehensive policies pay benefits in a skilled nursing facility, but the amount of coverage depends on the individual policy. For information on how to determine what kind of LTCI policy suits your needs, visit our Financing Long Term Care Expert Column.

Veterans Benefits

What It Covers

The Department of Veterans Affairs (VA) provides skilled nursing care to eligible veterans through VA and Community Contract facilities. Veterans who do not meet the conditions and limitations outlined below may still be eligible for nursing care when space and resources are available.

Conditions and Limitations

• Veteran must meet the eligibility criteria for VA benefits
• Require skilled nursing care for a service-connected condition; or
• Have a service-connected disability rating of 70% or more; or
• Have a service-connected disability rating of 60% and be considered unemployable
• Skilled nursing care for non-service connected veterans is limited to 6 months

Finding and Assessing Nursing Homes

Gilbert Guide provides national nursing home listings along with information on how to assess nursing homes and a detailed explanation of Medicare's scoring of nursing home deficiencies so that you can find a skilled nursing facility that will best fit your needs.

Posted in: Choosing the Right Nursing Home, Nursing Homes, Paying for Care, Weighing your Housing Options, When Is It Time to Move?

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