Medicare Medigap plans and Skilled Nursing
It's important to understand how Medicare and Medigap plans will handle the ever increasing use of Skilled Nursing care. With the big push to move people from facility based care (think hospital during a surgery) to less intensive skilled nursing care either in a facility or at your home following such a surgery, we want to make sure to adequately understand how it handled by Medicare and the plans that supplement it called Medicare supplements. First, let's start with an explanation of what skilled nursing is and more importantly, what it is isn't.
Skilled nursing is generally care provided to a person by nursing staff. This may sound redundant but it's important to clearly understand it. Such care may be the maintenance of IV's or physical therapy. In general, it's the next care level down from that provided under a direct doctor's supervision. In order to receive benefits under Medicare for skilled nursing, the practitioners and/or facility must be Medicare approved so make sure this is the case before proceeding especially with home based care. One note, skilled nursing is generally given to help you recover from a given situation (say following a surgery) or prevent a health condition from getting worse. It is generally considered short term based (up to 100 days with Medicare) and is not intended for custodial care. Custodial care is designed to help a person with everyday issues such as bathing, clothing, getting in/out of bed and the like if that's the only care that is needed. Custodial care falls under the heading of Long Term Care which is not covered under Medicare and requires other preparations such as purchasing a Long Term Care policy. Let's look at what Medicare considers to be "short term" when dealing with skilled nursing care.
We'll first look at Traditional Medicare's coverage of skilled nursing and then look at how Medicare supplements work to fill in the "gaps" in coverage. Traditional Medicare covers the first 100 days of skilled nursing with variable levels of coverage. For the first 20 days, Medicare will pay the qualified skilled nursing expenses in full with qualified providers. For days 21 through 100, you will pay a co-payment for the cost. The copay changes each year as most things with Medicare do but 2012's copay is $146. After day 100, traditional Medicare will not pay anything. So what starts the 100 day period. The rules are a little more involved but we'll try to summarize as best as we can with the added instruction that you should check the detailed Medicare rules for your particular situation.
In a nutshell, you need a 3 day stay in a hospital to trigger the 100 day potential period. There's no limit to the number of benefit periods but other rules apply. Outside of the 100 day cap, a benefit period will generally end if you haven't been in a hospital or received skilled nursing for 60 days. So how do Medicare supplements work with the traditional Medicare benefits?
Essentially, the C-G plus M,N Medicare Medigap plans will cover the copay ($146 for 2012 per day) that Medicare does not pick up. The K and L plan will cover a percentage of the Skilled Nursing co-pay (50 and 75% respectively). A Medicare supplement does not extend your total # of days past the 100 mentioned which is important to understand for longer term care issues (again, Long Term Care comes into light here). Skilled nursing is increasingly a common way for facilities to reduce costs and free up bed space as a midway level of care. Expect this trend to continue going forward and this need speaks loudly to the benefits of the F Medicare supplement plan among other reasons.