What are Medicare Nursing Homes?

Medicare nursing homes are nursing homes or skilled nursing facilities that participate in the US government Medicare program. This means they accept Medicare payments, for the limited time in which nursing home care is allowed, and they may also participate in Medicaid programs. In order to participate in either government health program, a nursing home must meet certain standards set by the Centers for Medicare and Medicaid Services (CMS), and needs to pass an initial inspection by state contracted inspectors. Additional yearly inspections are typically required to make certain that Medicare nursing homes are continuing to provide quality care, and there are measures that may be taken if they’re not.

It would make sense to assume that inspecting Medicare nursing homes would necessarily assure a high level of quality in all of these facilities. Yet this is not the case, and in order to add some additional protection for those requiring skilled nursing in a facility, CMS launched a nursing home rating and finder tool on the Health and Human Services website. Not only does the Medicare compare tool give information on nearby nursing homes that participate in Medicare, but it also uses a five star rating system to assess total quality of facilities and quality as judged by amount and type of staff, health inspection results, and analysis of quality measures as reported by the nursing home.

Tools like Medicare compare are useful in trying to find a nursing home that meets requirements and certain quality standards. Most advise that these tools not be the only criteria used and that there are variations in the way inspection is carried out from state to state, which can skew results. Visiting nursing homes to determine their overall cleanliness, feel, and helpfulness of staff is important too, and then visiting the person staying at the nursing home is vital to make certain their needs are being met and there is no evidence of neglect or abuse. Despite the oversight system provided by CMS, poor care or abuse may still exist in nursing homes, and families should do all they can to provide additional oversight so that patients receive the best care possible, including, if necessary, moving a person to a different nursing home.

In addition to people assessing quality of Medicare nursing homes as part of helping to determine which facilities are best for loved ones, people should know something about coverage offered through Medicare for nursing homes. Under standard Medicare, nursing home coverage is only offered if a person needs skilled nursing or rehabilitation. It is not offered to help with basic care like feeding, clothing or toileting needs, if these are the only needs. Skilled nursing could include medical procedures like injection of medications and rehabilitation might include work with various therapists to help regain some function.

Stay in a Medicare nursing homes is only covered at full cost for 20 days, and on day 21, people are assessed a daily copayment of $128 US Dollars (USD). This amount could vary slightly if people have supplement policies like Medicare Advantage Plans or Medigap. In total, Medicare will only pay for 100 days of coverage, with the last 80 days usually requiring copayments from the person hospitalized. If more hospitalization is required, this may be assessed at full cost, and is one of the reasons why some people end up draining any savings they have. Should resources be small, some people might be eligible for Medicaid coverage, which could help with the cost of additional days or those with long term care insurance could have additional coverage that meets extra costs and may extend days of coverage.

While many people have family who can help them make decisions about Medicare nursing homes, some people are alone in this decision. When this occurs, there are some places to get support. People can talk to doctors or social workers to determine best places or they may want to contact those they know in the community like pastors or rabbis. Another useful resource for many folks is a state long-term care ombudsman, since these are advocates for nursing home residents and can provide some extra support or advice.