MEDICARE’S 100 DAYS OF COVERAGE

As those of you who read my column know, I practice elder law. Most every day of the week, I am either discussing an issue of elder law with a client or working on a client’s elder law issue.

In my practice I frequently encounter people with similar problems and concerns. Although we all like to think of ourselves as being unique, the challenges that we face are often very similar. And our reaction to those challenges and the misconceptions that we harbor about those challenges are also very similar.

There are three misconceptions that I hear almost every week: “I thought I could only gift $10,000 a year”; “I thought I was ineligible for Medicaid for 36 months”; and “Medicare will pay for the first 100 days of mom’s stay in the nursing home.” Two of these misconceptions I have already addressed in previous columns.

As I indicated in one of those prior columns, unless you have assets worth more than $1,000,000, you could gift every dime you own and pay no tax at all; you are not limited to $10,000 (actually $11,000 now) a year. If you do gift more than $11,000 in any one-year to any one person, you have to file a federal gift tax return, but there is no tax owed.

Furthermore, as indicated in a prior article, there is no automatic ineligibility for Medicaid for 36 months, and many people could save tens of thousands of dollars with proper planning, qualifying for Medicaid benefits much sooner than 36 months. The key is to seek advice and seek advice fast, because once someone you know needs long-term care, time is against you. The longer you procrastinate, the more you lose and the longer you must wait to qualify for Medicaid benefits.

The last of the three big misconceptions that I hear on a regular basis deals with Medicare coverage for nursing home stays. Medicare is a health insurance program. For most people over the age of 65, Medicare is their primary health insurance.

Medicare will pay for some care in a nursing home, up to 100 days, but the trick is, the coverage is only provided in certain situations and the 100 days of coverage is a maximum amount of coverage, not a guarantee of coverage. A Medicare recipient could receive 100 days of coverage, 0 days, or any number of days between 0 and 100.

In order to receive any days of coverage, a Medicare beneficiary must be hospitalized for at least 3 days, not counting the day of discharge, and the beneficiary must enter a nursing home within 30 days of being discharged from the hospital. Once in the nursing home, Medicare will only pay for skilled or rehabilitative care.

Skilled care differs from custodial, long-term care. Custodial care is the type of care that we typically think of when we think of nursing home care. Custodial care is usually provided to persons who are not expected to get better. They may live in the nursing home for the remainder of their lives, unable to fully care for themselves.

Skilled care is for people who are expected to get better. For instance, someone who falls and breaks a hip would probably first go to a hospital for surgery and then to a nursing home for some rehabilitation of the newly mended hip.

The thing with the 100 days is, if a person is not getting better, which is often the case with elderly individuals, then they probably won’t be covered by Medicare. The nursing home will then tell the family that their father or mother must either leave the nursing facility or private pay for his or her care.

Those individuals who believe that any of the 100 days of Medicare coverage is guaranteed are often in for a rude awakening. Although I do not have statistics on this issue, my experience has been that most Medicare recipients do not receive the full 100 days of coverage; in fact, most do not receive anything near the 100 days of coverage.