Navigating Medicare Restrictions When Choosing a Nursing Home: Important Things to Consider for Care Placement
Choosing a nursing home is a huge decision, and it’s essential to understand how Medicare’s coverage rules and restrictions can affect your options. While Medicare does offer vital health benefits, its limitations on skilled nursing facility (SNF) care and the requirements for facility certification can greatly influence where you receive care. This guide will walk you through the specifics of Medicare restrictions, how insurance impacts care placement, and the life events that allow you to switch your Medicare plan outside of the usual enrollment periods.
Understanding Medicare’s Limitations for Nursing Home Care
Medicare’s coverage for nursing home stays is specifically designed for short-term skilled care rather than long-term custodial assistance. Here’s what you should know:
1. The 3-Day Hospital Stay Requirement
To be eligible for Medicare-covered SNF care, you need to have a 3-day inpatient hospital stay (not including observation status) and enter a Medicare-certified facility within 30 days after discharge. This rule is in place to ensure that coverage addresses acute medical needs, like rehabilitation after surgery or recovering from a stroke. However, there are exceptions:
Medicare Advantage (Part C) plans might waive the 3-day rule under certain circumstances, although prior authorization is typically required.
Accountable Care Organizations (ACOs) or other Medicare programs may also eliminate this requirement for eligible patients.
2. Skilled Care vs. Custodial Care
Medicare only covers skilled services that are medically necessary, such as wound care, physical therapy, or IV medications. Custodial care—which includes help with daily activities like bathing or eating—is not covered unless there are skilled needs involved. This means many long-term nursing home residents may have to turn to Medicaid or pay out of pocket once their Medicare benefits run out.
3. 100-Day Benefit Period and Cost Sharing
Medicare Part A covers up to 100 days for each benefit period, but full coverage stops after day 20. For days 21 to 100, beneficiaries will need to pay daily coinsurance ($209.50 in 2025) unless they have supplemental insurance. After 100 days, all costs fall to the patient or through Medicaid if eligible.
How Medicare Restrictions Impact Nursing Home Placement
Network Limitations and Facility Certification
Medicare will only cover care in Medicare-certified SNFs, which need to meet federal standards for staffing and services. This creates two main challenges:
- Limited Facility Options: Many nursing homes are geared toward long-term custodial care and don’t have Medicare certification, limiting options for those needing short-term rehab.
- Medicaid Transition Risks: If a patient runs out of Medicare benefits and qualifies for Medicaid, facilities with only a few Medicaid-certified beds might evict them unless they find a Medicaid bed.
Prior Authorization and Plan-Specific Rules
Medicare Advantage plans usually have extra restrictions:
- Network Requirements: Most plans require you to use in-network SNFs, which may not fit with a patient’s preferred facility.
- Coverage Appeals: If a plan denies coverage for SNF care, beneficiaries need to go through appeals to show that their stay is medically necessary.
Life Events That Allow Medicare Plan Changes Outside Open Enrollment
You’re not limited to just the Annual Enrollment Period (October 15–December 7) for adjusting your coverage. Certain life events can trigger Special Enrollment Periods (SEPs):
1. Relocation
- Moving outside your current plan’s service area.
- Entering or leaving a nursing home.
2. Loss of Existing Coverage
- Losing employer-sponsored health insurance.
- A plan terminating its contract with Medicare.
3. Eligibility for Medicaid or Extra Help
Becoming eligible for Medicaid or the Low-Income Subsidy (LIS) allows you to switch to a Dual-Eligible Special Needs Plan (D-SNP).
4. Institutionalization or Discharge
- Being admitted to or discharged from a skilled nursing facility or long-term care hospital.
- During these events, beneficiaries can enroll in a new Medicare Advantage or Part D plan within 60 days of the occurrence.
Navigating Medicare Restrictions with Expert Guidance
Medicare’s complicated rules—from the 3-day hospital stay rule to network limitations—emphasize the importance of proactive planning. For families dealing with nursing home transitions, it’s crucial to understand these restrictions to prevent gaps in coverage or unexpected costs. Likewise, events like moving or qualifying for Medicaid present chances to reassess coverage needs beyond the regular enrollment periods.
At Antanavage Farbiarz Attorneys at Law, we specialize in helping clients untangle the complexities of Medicare, advocate for coverage approvals, and find sustainable care solutions. Whether you’re preparing for short-term rehab or long-term custodial needs, our team is dedicated to ensuring your rights and financial interests are safeguarded.
By staying informed about Medicare restrictions and eligibility triggers, you can make informed decisions for yourself or your loved ones during some of life’s toughest transitions.
Our family is here for your family – give us a call at (610) 562-2000 or click here to schedule a consultation.
Stay up to date with the latest tips from Antanavage Farbiarz, PLLC by following us on Facebook and LinkedIn.