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What qualifies a patient to receive restorative nursing care in the United States?
Hello! Thanks for your question about what qualifies a patient to receive restorative nursing care in the United States.
The short version is that a patient may receive financing for restorative nursing care in a skilled nursing facility (SNF) through Medicare, state Medicaid programs, Medi-Cal, or private insurance. These have varying but closely related requirements regarding patient needs and length of stay in the facility.
Below you will find a deep dive of my findings.
MEDICARE PART A
According to Elder Law Answers and other sources, Medicare Part A covers 100 days of skilled nursing care for patients provided that:
◆ The recipient enters the facility 30 days after staying in the hospital for at least 3 days as an inpatient (the day of discharge is not counted).
◆ The care rendered in the SNF must be for the same or medically related condition as that of the original hospitalization.
◆ The recipient must receive skilled/restorative nursing care in the SNF that cannot be received at their home or as an outpatient.
◆ Skilled and restorative nursing care must be received by the patient on a daily basis.
The article adds that as soon as the SNF determines the patient is no longer receiving restorative nursing care, Medicare coverage ends. Also, on day of the recipient's stay, there will be a co-payment of the initial hospital deductible worth $161 a day in 2016. Medigap insurance usually covers this co-payment if the patient possesses one.
STATE MEDICAID
States offer Medicaid coverage for patients receiving restorative nursing care in SNFs, however they vary in the limitations of assets that a recipient can hold and qualify for Medicaid. However, Medicaid requires Preadmission Screening and Resident Review (PASRR) from recipients applying for long-term care in a skilled nursing facility.
Medicaid also informs that all states have established their own nursing facility level of care criteria, and that some states set arbitrary eligibility limits for recipients applying as a resident in a nursing facility. These are provided by the state's Medicaid agency.
MEDI-CAL
As with Medicaid, Medi-Cal coverage for restorative nursing care and other long-term nursing care is combined with state medical assistance programs. For example, in California Medi-Cal pays 43% of publicly funded long term care services in the state. Eligibility for Medi-Cal is more complicated but can be generally categorized into two groups:
◆ Categorically Needy - recipients who receive cash assistance through government and public programs automatically qualify for Medi-Cal.
◆ Medically Needy - recipients who incur medical expenses each month, which may include low-income Medicare beneficiaries.
PRIVATE INSURANCE
Patients may also finance their stay in skilled nursing facilities to receive restorative nursing care through private insurance. Some examples are:
◆ Blue Cross Blue Shield of North Carolina - offers Medicare C/D coverage for recipients that meet BCBS' criteria.
◆ United Healthcare offers coverage for recipients that meet 4 major factors regarding the patient's need for restorative nursing care and stay in an SNF.
CONCLUSION
To wrap it up, a recipient may apply for financing for restorative nursing care in a skilled nursing facility (SNF) through Medicare, state Medicaid programs, Medi-Cal, or private insurance. These medical insurance providers have varying but closely related requirements regarding patient needs as well as length of stay in the skilled nursing facility.
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