Home Health & Wellness Skilled Nursing Care Eligibility: What You Need to Know

Skilled Nursing Care Eligibility: What You Need to Know

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Finding the right doctor for your loved one can be a tough decision. If you’re dealing with senior health issues, you may have reached a critical juncture in your search for an assisted living community.

Sometimes, a nursing home just isn’t the best solution for your loved one’s needs. The good news is that the alternative may be a bit closer than you think.

If you’re in the process of searching for a nursing home for a loved one, you’re sure to have come across criteria for skilled nursing care eligibility.

If you’re wondering whether or not you should pursue this care option for yourself, there are some elements of your health you should know about and discuss with a licensed neurologist.

What is skilled nursing care?

Before we delve into eligibility criteria, let’s clarify what skilled nursing care is. In a specialised facility, licensed healthcare professionals provide skilled nursing care, also known as SNF care (skilled nursing facility care).

It’s designed for individuals who require 24-hour medical supervision and assistance with daily living activities due to:

  • Illness
  • Injury
  • Chronic conditions

Skilled nursing care is different from basic or custodial care, which primarily involves assistance with activities of daily living (ADLs) like bathing, dressing, and eating.

In contrast, skilled nursing care is centred around medical treatment and rehabilitation. When a patient’s condition necessitates a higher level of care than what is possible at home, a doctor will typically prescribe it.

The tricky terminology: SNF vs nursing home

Before we get into the nitty-gritty of eligibility, let’s clear up some terminology confusion. The terms “skilled nursing facility” (SNF) and “nursing home” are often used interchangeably, but they aren’t quite the same.

Skilled nursing facility (SNF)

An SNF is a healthcare institution that provides skilled nursing care on a short-term basis. It is typically used for post-hospitalization recovery or rehabilitation.

Some types of SNF deal with special cases. This type of care is exclusively offered for patients requiring nursing care and respiratory therapy services for tracheostomy, cool aerosol, and ventilator support.

Nursing home

A nursing home, on the other hand, offers long-term care for individuals who can no longer live independently. It can be due to physical or cognitive impairments. While some nursing homes do offer skilled nursing care, their primary focus is on custodial care and support for daily living activities.

Understanding this distinction is crucial because eligibility criteria can vary between SNFs and nursing homes. For this article, we’ll primarily focus on skilled nursing care in SNFs.

What qualifies a patient for skilled nursing care?

Now, let’s get to the heart of the matter. What qualifies a patient for skilled nursing care? A combination of logistical, financial, and medical factors determine eligibility. Here are the key criteria to consider:

Medical necessity

The primary determinant of skilled nursing care eligibility is medical necessity. This means that you must have a medical condition that requires skilled nursing care and therapy on a daily basis. Common examples include:

  • Post-surgery recovery
  • Stroke rehabilitation
  • Wound care
  • Respiratory therapy
  • Management of chronic illnesses like diabetes

Your doctor will assess your medical condition and prescribe skilled nursing care when it is deemed necessary. The need for this level of care must be documented in your medical records.

Hospitalisation requirement

In many cases, skilled nursing facility services follow a hospital stay. Medicare, a federal health insurance programme for people aged 65 and older, generally covers short-term stays in SNFs after a qualifying hospital stay.

To be eligible, you typically need to have spent at least three consecutive days as an inpatient in the hospital (observation days do not count) and require skilled care related to your hospitalisation.

Physician’s certification

Your attending physician plays a crucial role in determining your eligibility for skilled nursing care. They must certify that you need skilled nursing care daily and that the care you receive in an SNF is related to a condition that was treated during your qualifying hospital stay.

Financial considerations

While medical necessity is the primary criterion, financial factors can also affect your eligibility. If you have Medicare coverage, it might pay for the first 20 days of your skilled nursing care in full. For days 21 through 100, a daily coinsurance fee applies. Beyond day 100, Medicare coverage ends.

If you don’t have Medicare or if your benefits run out, you’ll need an alternative source of payment. This can include private insurance, Medicaid (a joint federal and state programme for low-income individuals), or out-of-pocket payments.

What is Medicaid?

Medicaid is a joint federal and state programme that provides healthcare coverage to eligible low-income individuals and families. Medicaid can be a lifeline for those who require skilled nursing care but do not have the financial means to cover the cost. Medicaid eligibility varies by state and is typically based on factors such as:

  • Income
  • Assets
  • Medical necessity

In some cases, individuals may qualify for both Medicare and Medicaid, which can help cover a broader range of healthcare services, including skilled nursing care.

Understanding Medicare’s role

Medicare is a critical player in skilled nursing care coverage for many seniors. Here’s a closer look at how Medicare eligibility works for SNF care:

Medicare Part A

Medicare Part A is the hospital insurance component of Medicare. It covers inpatient hospital stays, including the first 20 days of skilled nursing care in an SNF after a qualifying hospital stay. To be eligible for Medicare Part A, you generally need to meet the following criteria:

  • You are 65 or older.
  • You have certain disabilities.
  • You or your spouse paid Medicare taxes while working.

Medicare Part B

Medicare Part B is the medical insurance component of Medicare. It covers:

  • Outpatient services
  • Physician visits
  • Some preventive services

While Part B doesn’t cover the cost of a full stay in an SNF, it does cover certain medical services you may receive while in an SNF.

Medicare Advantage plans

Some individuals choose to enrol in Medicare Advantage plans (Part C), which are offered by private insurance companies approved by Medicare. These plans often provide coverage for skilled nursing care and may have different eligibility criteria and cost-sharing structures than traditional Medicare.

Medicare supplements

Medicare Supplements, also known as Medigap policies, can help cover costs that Original Medicare (Part A and Part B) doesn’t cover, including some SNF care expenses. Eligibility for Medigap policies varies by state.

It’s important to consult with a Medicare specialist or your local State Health Insurance Assistance Program (SHIP) to understand your specific Medicare coverage and eligibility.

Making the Transition

The transition from a hospital to a skilled nursing facility can be challenging. But it’s a crucial step in the recovery process for many individuals. Here’s what you can expect during this transition:

Assessment and planning

Before your discharge from the hospital, a care team, including social workers and nurses, will assess your needs and help plan your transition to an SNF. This involves coordinating with the SNF to ensure a smooth transfer of care.

Choosing an SNF

If possible, you or your family will have the opportunity to choose the SNF that best meets your needs and preferences. Consider factors like location, quality ratings, and the specific services offered when making your selection.

Admission process

Once you’ve chosen an SNF, the admissions process begins. This typically involves completing paperwork, providing insurance information, and arranging transportation to the facility. Your medical records will be sent to the SNF to ensure continuity of care.

Care plan development

Care plan development is an essential aspect of skilled nursing care. It involves creating a personalised and comprehensive plan to address the individual’s specific needs and goals. This includes collaboration with healthcare professionals to provide the best possible care, as well as a thorough assessment of their

  • Physical needs
  • Emotional needs
  • Social needs

Understanding skilled nursing care eligibility is crucial for the successful development and implementation of a personalised care plan.

Family involvement

One factor that is often overlooked is the involvement of the family in the care process. Family involvement plays a crucial role in ensuring that the individual receives the best possible care and support.

Families need to understand the eligibility criteria and be actively involved in the care plan for their loved ones. This can not only improve the quality of care but also provide emotional support for both the individual receiving care and their family members.

Empowering yourself with knowledge

In conclusion, understanding what qualifies a patient for skilled nursing care is crucial for any individual or family planning for long-term care options. By meeting the necessary criteria, individuals can access high-quality and personalised care from trained professionals.

If you or a loved one may benefit from skilled nursing care, don’t hesitate to reach out to qualified healthcare providers for more information and assistance. Take charge of your long-term care plan today.

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David Radar , a psychology graduate from the University of Hertfordshire, has a keen interest in the fields of mental health, wellness, and lifestyle.

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