Sam, who is 80 years old, recently had a stroke. Fortunately for Sam and
his family, he is on the road to recovery. After an initial 4 day stay
in the hospital, Sam was released to a skilled nursing facility for rehab.
He needed to regain his strength and his balance. After 8 weeks in the
skilled nursing facility, Sam was strong enough to go home.
As the bills started arriving, Sam was happy to see that between his basic
Medicare insurance and his Medicare supplemental insurance policy, most
of his hospital and skilled nursing bills were covered.
Dave, who is also 80 years old, had his second stroke a few months ago
and like Sam, went from the hospital to the skilled nursing facility for
rehab. Unfortunately, Dave is not regaining his strength and balance this
time and is coming to the realization that for his own safety, he may
need to live in the skilled nursing facility indefinitely rather than
As Dave is beginning to make peace with the fact that his continued need
for substantial assistance means he isn't going home, he learns that
although his basic Medicare insurance and Medicare supplemental policy
paid for his rehab stay in the skilled nursing home, it will not pay for
him to continue to live in the skilled nursing home.
Why will Medicare no longer pay for Dave to stay in the skilled nursing
facility? Because Dave's reason for being in the skilled nursing facility
is changing from rehab care due to a health event to custodial care due
to an inability to live independently without substantial assistance.
Medicare is health insurance; therefore, it only works for health related
events. As we saw with Sam, sometimes in order to recover from a health
event, a temporary stay in a skilled nursing facility is required. However,
this experience can lull a Medicare recipient into thinking that Medicare
will pay for any stay in a skilled nursing facility. As Dave has realized,
it does not.
As a general rule, the maximum number of health event triggered skilled
nursing days that Medicare will pay for is 100 days. A Medicare rehab
stay is triggered by a health event that results in an admission into
the hospital for a minimum period of 3 overnights and a discharge to rehab
care. Medicare will pay 100% of the cost for the first 20 days of rehab
and then up to 80% of the cost for the next 80 days. If you have a Medicare
supplemental policy, your 20% co-pay for days 21 – 100 will most
likely be covered by the supplemental policy. If you do not have a Medicare
supplemental policy, the 20% co-pay becomes your responsibility (with
a daily rate of over $200 per day, the 20% co-pay can add up quickly).
How does someone without a Medicare supplemental policy or someone like
Dave, who needs to live in a skilled nursing facility in custodial care
status rather than rehab status pay for the cost of their care? Usually
with a combination of personal savings, family assistance and long-term
care insurance. What does someone who doesn't have enough savings
or the luxury of family assistance or the peace of mind of long-term care
insurance do? They have to see if they can get assistance with the costs
from government benefits such as Medicaid.
So, don't be lulled into a false sense of security by thinking that
Medicare will cover the cost of your stay in a skilled nursing facility.
As we have seen through Sam's and Dave's experiences, except in
limited health event rehab situations like Sam's, Medicare will not
provide the safety net you need for your long-term care.