Medicare Part A covers up to 100 days of
"skilled nursing" care per spell of illness. However, the conditions
for obtaining Medicare coverage of a nursing home stay are quite stringent. Here
are the main requirements: 

1. The Medicare recipient must enter the nursing
   home no more than 30 days after a hospital stay that itself lasted for at least
   three days (not counting the day of discharge);
2. The care provided in the nursing home must be
   for the same condition that caused the hospitalization (or a condition medically
   related to it); and
3. The patient must receive a "skilled"
   level of care in the nursing facility that cannot be provided at home or on an
   outpatient basis. In order to be considered "skilled," nursing care
   must be ordered by a physician and delivered by, or under the supervision of, a
   professional such as a physical therapist, registered nurse or licensed
   practical nurse. Moreover, such care must be delivered on a daily basis. (Few
   nursing home residents receive this level of care.)

As soon as the nursing facility determines that a
patient is no longer receiving a skilled level of care, the Medicare coverage
ends. And, beginning on day 21 of the nursing home stay, there is a significant
copayment equal to one-eighth of the initial hospital deductible ($124 a day in
2007). This copayment will usually be covered by a Medigap insurance
policy, provided the patient has one.

A new spell of illness can begin if the patient
has not received skilled care, either in a skilled nursing facility (SNF) or in
a hospital, for a period of 60 consecutive days. The patient can remain in the
SNF and still qualify as long as he or she does not receive a skilled level of
care during that 60 days.

Nursing homes often terminate Medicare coverage
for SNF care before they should. Two misunderstandings most often result in
inappropriate denial of Medicare coverage to SNF patients. First, many nursing
homes assume in error that if a patient has stopped making progress towards
recovery then Medicare coverage should end. In fact, if the patient needs
continued skilled care simply to maintain his or her status (or to slow
deterioration) then the care should be provided and is covered by Medicare.

Second, nursing homes may wrongly believe that
care requiring only supervision (rather than direct administration) by a skilled
nurse is excluded from Medicare’s SNF benefit. In fact, patients often receive
an array of treatments that don’t need to be carried out by a skilled nurse but
which may, in combination, require skilled supervision. In these instances, if
the potential for adverse interactions among multiple treatments requires that a
skilled nurse monitor the patient’s care and status, then Medicare will continue
to provide coverage.

When a patient leaves a hospital and moves to a
nursing home that provides Medicare coverage, the nursing home must give the
patient written notice of whether the nursing home believes that the patient
requires a skilled level of care and thus merits Medicare coverage. Even in
cases where the SNF initially treats the patient as a Medicare recipient, after
two or more weeks, often, the SNF will determine that the patient no longer
needs a skilled level of care and will issue a "Notice of
Non-Coverage" terminating the Medicare coverage.

Whether the non-coverage determination is made on
entering the SNF or after a period of treatment, the notice asks whether the
patient would like the nursing home bill to be submitted to Medicare despite the
nursing home’s assessment of his or her care needs. The patient (or his or her
representative) should always ask for the bill to be submitted. This requires
the nursing home to submit the patient’s medical records for review to the
fiscal intermediary, an insurance company hired by the Health Care Financing
Administration to administer the Medicare program.

The review costs the patient nothing and may
result in more Medicare coverage. While the review is being conducted, the
patient is not obligated to pay the nursing home. However, if the appeal is
denied, the patient will owe the facility retroactively for the period under
review. This should be addressed. If the fiscal intermediary agrees with the
nursing home that the patient no longer requires a skilled level of care, the
next level of appeal is to an Administrative Law Judge. This appeal can take a
year and involves hiring a lawyer. It should be pursued only if, after reviewing
the patient’s medical records, the lawyer believes that the patient was receiving a
skilled level of care that should have been covered by Medicare. If you are
turned down at this appeal level, there are subsequent appeals to the Appeals
Council in Washington, and then to federal court.

After an individual has exhausted his Medicare coverage, the only means of payment for long term nursing home care are private funds, private insurance, or Medicaid once the individual qualifies.