Medicare Guidelines, Services, & FAQs at Rolling Hills
Medicare Information and Guidelines
In order to have a nursing home stay covered by Medicare Part A at Rolling Hills, residents need to meet certain criteria:
- The patient must be enrolled in Medicare Part A at that time of the qualifying hospital stay. You must have a 3 consecutive night inpatient stay to qualify for Medicare A admission. A hospital stay in observation does not qualify per Medicare A requirements.
- Be admitted to Rolling Hills and begin Part A coverage within 30 days of the hospital discharge (the day of discharge is not counted) and be there for the same condition as you were in the hospital for.
- A doctor must certify that you need, and must receive, skilled nursing or skilled rehabilitation services on a daily basis and show daily progress toward set goals.
The decision to admit a patient to the nursing home under the Medicare Benefit is determined by a Registered Nurse and Interdisciplinary Team (IDT) from the facility. The IDT will review your medical record and data from the hospital. Sometimes there is confusion about the need for skilled nursing. This decision can only be made by the admitting nursing home based on the information from the hospital stay and the patient’s condition at the time of admission.
Medicare Frequently Asked Questions
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If a resident qualifies for Nursing Home Medicare Part A, they may receive up to 100 days of coverage per benefit period. He or she will need to have a 3 day (24 hour days) inpatient hospital stay prior to admittance or a 3 day hospitalization within 30 days of admittance to the facility.
Medicare Pays in full for days 1-20.* However, days 21-100 have $164.50 per day co-insurance amount that is the responsibility of the resident. However, this may be covered by private insurance and the insurance company will need to be contacted by your to determine if this will be covered.
*NOTE: This coverage is dependent upon meeting the criteria Medicare has set.
If patients do qualify for coverage under Medicare Part A, days 1-20 are paid by Medicare in full. For days 21-100, patients will be responsible for a co-insurance amount of $164.50 per day as long as they continue to qualify to meet Medicare Part A criteria. The responsible party must contact your private insurance company to clarify coverage. If the coverage does not cover any part of your stay during coverage under Medicare Part A, you are personally responsible for co-insurance payments.
Medicare Part A only allows 100 days for each benefit period. In order to receive a new benefit period, it would require 60 consecutive days at a non-skilled level after the first benefit period ended. Then patients would have to meet the criteria above to receive Medicare Part A benefits again.
Throughout each resident’s Medicare Benefit stay, the facility staff will keep them up-to-date of the number of days they have completed in the benefit and of the levels of skilled nursing. When the decision is made that the resident’s level of care no longer meets Medicare guidelines, he or she will be informed and given a “Notice of Denial” form that will end the benefit period. Prior to this time, the residents nurse and social worker will discuss a plan for discharge and what may expected at that time.
If you have Medical Assistance or a Medicare supplement, Rolling Hills will submit your co-insurance to them for reimbursement.
Medicare Covered and Non-Covered Services
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- Semi-private room accommodations, except where private room is medically necessary or semi-private rooms are unavailable.
- Skilled Nursing Care – not private duty nurse.
- Physical Therapy, Speech Therapy, and Occupational Therapy Services furnished by facility or others unless by arrangement. Billing is by the Skilled Nursing Facility.
- Drugs, biologicals, supplies, appliances, and equipment that is used regularly in a Skilled Nursing Facility.
- Other diagnostic or therapy services provided by participating Skilled Nursing Facility
- Private duty nursing care.
- Services that the facility generally doesn’t have (i.e. surgical services, etc.)
- Nursing Home services that do not meet the Skilled Nursing Facility requirements, no Intermediate Care.
- All transportation charges.
- Long distance personal telephone calls.
- Bedhold during hospitalization or home visit.
“I enjoy the camaraderie with all the activity staff and other volunteers. I’m always amazed how many of the activity staff make a point to thank us.”