How Does it Affect Medicaid and Payment to Nursing Home?

• Medicare: For those 65 years and older or those determined disabled by Social Security Admin (SSA). Traditional or original Medicare has Parts A and B. Part A covers hospitalization and short-term rehab in a nursing facility for up to 100 days if you meet requirement for medical necessity. Part B covers out-patient services including doctor visits. MC covers 80% of cost, 20% is client responsibility unless they carry a supplemental or secondary policy which will pick up the 20%. For example, BC/BS or an AARP plan.
• Traditional MC offers limited nursing home coverage: Only 20 days paid in full, then an additional 80 days at 80% copay.  If they meet medical necessity requirements for their definition of skilled care. Traditional MC also requires a 3-day qualifying hospital stay in order to cover a rehab stay. That means you must be overnight in the hospital as a full admission for a medically necessary stay. (Observation stays and admission denials or medical necessity denials before 3 full days will disqualify you from getting MC coverage at the nursing facility for your rehab stay.)
• Medicare Advantage Plan: Is a Medicare Part C plan – they combine the coverage of Traditional Medicare with the additional coverage of a supplemental plan. For example – IHA Encompass 65 is a MC Advantage plan – it will cover up 100% of medically necessary services. For a short-term rehab stay they will cover up to 100 days if the client continues to meet medical necessity guidelines, but they may have copays. The added benefit is that they have the right to waive traditional MC requirement of a 3-day qualifying hospital stay prior to authorizing a short form term rehab stay.
• Commercial Insurance Plans: May pick up the 20% Medicare co-payment for a short-term rehab stay. Typically, they do not offer coverage for skilled nursing care. For example, someone under 65 who may still be working and has a commercial IHA plan likely will not have any skilled nursing coverage included in their plan.