"Doesn't my loved one qualify for 100 paid days by Medicare in a nursing home?"
This is probably the most common question I get in my position.
The technical answer to this is yes, but the reality of this question is no.
First off, it is important to ask which primary Medicare plan does the person have?
- Traditional Medicare (Government operated)
- Medicare Replacement or Advantage Plan (Private Company operated)
Traditional Medicare will pay for 20 days of rehab at 100%. If the patient must stay longer for rehab, Medicare will continue to pay a portion and the patient must pay a large daily co-pay (2023 it is $200 per day).
Medicare Advantage Plans
The Medicare Advantage plans like Humana or AARP have their own co-pay structure for rehab in a skilled nursing facility that is similar.
So what is the big catch?
One word, Rehab.
In order to continue to qualify for rehab in a skilled nursing, the patient must continue to show progress and participle in rehab. If that progress slows (not getting better as fast as the insurance would like) or stops due to their health situation, both traditional Medicare and the private Medicare advantage plans will stop paying all together.
On average, I see the private company plans stop paying after about 15-30 days and Traditional Medicare usually stops paying after 30-40 days. This is from my own experience, and may not be applicable to your situation. These are just averages from what I see.
So the answer to the question, “Doesn’t my loved one qualify for 100 paid days by Medicare in a nursing home?”, is:
They could, but likely not, and even more likely not paid at 100%.
⁃ Justin Embry