Medicare is a federally-sponsored health insurance program for persons over age 65 and certain disabled individuals under age 65. Everyone who is eligible for Social Security or other government pensions as result of their own, or their spouse’s employment history, is also eligible for Medicare. Medicare does not cover the cost of non-acute or “custodial care,” such as non-medical home care, independent or assisted living or memory care. If it is determined to be medically necessary, Medicare will cover up to 100 days per benefit period in a skilled nursing facility (SNF) if the person was hospitalized for at least three days within 30 days of admission to the SNF. The clock can start for a new benefit period if the person is readmitted to the hospital for a new condition, or if more than six months have passed since their last discharge from a SNF for the same condition.

Medicare covers 100% of the cost of the SNF for the first 20 days. For 80 days after that, Medicare covers 80% of the cost. If the person has a supplemental insurance policy, that policy will cover all or part of the remaining 20%; if not, the person is responsible for that co-pay. Once Medicare will no longer cover the SNF, either because they’ve decided it’s not medically necessary or the 100 days has run out, a supplemental policy won’t cover it either.

For seriously ill people, Medicare covers up to 80% of the cost of an additional 60 days. This is a lifetime allowance, so once the additional 60 days has been used, they are no longer available, even for a new benefits period.

Medicare pays for most (but not all) home health care if it was included in the discharge orders from the SNF, or if a physician prescribes it. There is no cap on the amount or duration of care covered, as long as there is a doctor’s order of medical necessity.

At times it is necessary to have a Medicare attorney assist with healthcare advocacy regarding Medicare benefits. Our team at Marsha Goodman, an Elder Law Attorney, helps to ensure that clients receive the benefits to which they are entitled under Medicare. As part of our Life Care Plans, we can help clients with plan changes during open enrollment periods and assist with resources when there are claim disputes or Medicare denials.