Many older adults think of Medicare as the insurance that will cover most of their future care needs. They are often surprised to learn that Medicare’s coverage for skilled nursing home care is quite limited. Specific rules determine if and when such coverage will start, continue and definitely end.

Medicare’s coverage for nursing home care is limited to post-hospital extended care. This means that after the insured patient was hospitalized for at least three consecutive days, the treating physician confirmed the need for continued professional care in a skilled nursing facility.

To receive such coverage, the patient must be admitted to the facility within 30 days of being discharged from the hospital. In 2011, Medicare may provide full coverage for days 1 through 20. For days 21 through 100 the patient will need to pay a daily co-payment of $141.50. For each period of hospitalization, Medicare’s coverage for extended care services will never exceed 100 days.

Unfortunately, a particular patient’s right to receive extended care coverage is seldom clear-cut. In fact, Medicare will only cover skilled nursing home care if it defines the provided services as being medically necessary to improve or prevent deterioration of the patient’s existing health status.

Medicare’s approval of continued coverage is often inappropriately revoked when a determination is made that the patient’s condition has “plateaued” and will not improve. Such a response is clearly incorrect. Federal statutes and regulations specifically provide that Medicare’s coverage for skilled nursing home care may not terminate within 100 days if the cessation of care might negatively impact the patient’s health and well-being.

Before deciding to discontinue coverage, Medicare must provide at least two days notice of its plan. The patient or patient’s representative who believes that Medicare’s coverage of necessary care should not cease may file an expedited appeal with the Health Service Advisory Group – the qualified improvement organization or QIO authorized by Medicare to review its decisions – by contacting them no later than noon of the proposed date of final coverage.

The QIO must advise the patient or patient’s representative of its determination within 72 hours. This must be followed with a formal written notice that includes a detailed explanation and information regarding the patient’s legal right to appeal.  Further stages of appeals can include filing a request for reconsideration, administrative hearing, and even litigation in the federal court.

Perhaps the most important fact to remember is that Medicare’s authorization for 100 days of nursing care coverage cannot be extended. Should the patient need to remain in a skilled nursing facility, Medicare will not provide financial support.  Instead, the patient will be responsible for all future costs.  It is for this reason that many patients end up relying on such financial options as long-term care insurance, Veterans entitlement programs, and Medi-Cal coverage for nursing home care.

For assistance in appealing a Medicare denial of coverage for skilled nursing or other healthcare, contact the Center for Health Care Rights at 800-824-0780.