Does Medicare Cover Nursing Homes in Texas?
Oct 01, 2024
This article about Texas Medicare pay for nursing home by elder law attorney Joy C. McNair and the McNair Law Group PLLC is not legal advice. It is for informational purposes only. To get specific legal advice in Texas, contact our law firm today at (281) 407-9830.
Navigating healthcare coverage can feel overwhelming, especially when figuring out what Medicare covers for nursing home care.
Whether you're a senior, caregiver, or family member seeking clarity, understanding how Medicare and Medicaid work, specifically in Texas, is crucial for making informed decisions about long-term care.
Nursing Home Or Skilled Nursing Facility: Which Is It?
Before diving into the specifics of what Medicare will pay for a nursing home in Texas, it's important to understand the terms "nursing home" and "skilled nursing facility" (SNF). While many believe these refer to two different types of facilities, they are generally the same.
This is important because the type of facility strongly dictates the available services and benefits.
A nursing home or skilled nursing facility may also be known as a long-term care facility. Portions of the facility may be more focused on short-term rehabilitation after an illness, injury, or surgery.
SNFs provide specialized medical care and therapy services to help patients recover and regain their independence. They may also offer additional services like medication management, wound care, and respiratory therapy.
These facilities also provide 24-hour medical care for individuals who need assistance with activities of daily living (ADLs) due to physical or cognitive disabilities. This type of care is typically for those with chronic conditions or disabilities that make living independently difficult.
What Does Medicare Pay for Nursing Homes in Texas?
Medicare provides limited coverage for nursing home care. It's essential to note that Medicare does not cover long-term stays in a nursing home where custodial care (such as assistance with bathing, dressing, or eating) is the only type of care needed. However, it does cover short-term stays for specific, medically necessary skilled nursing care after a hospital discharge.
Services Medicare Covers for Texas Nursing Home Costs
Medicare Part A can cover up to 100 days of skilled nursing facility (SNF) care each benefit period under certain conditions:
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The individual must have had a qualifying hospital stay of at least three days before entering the nursing facility.
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A doctor must certify that skilled nursing care is needed.
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The services must be provided in a Medicare-certified skilled nursing facility.
Medicare Benefits: What Medicare Skilled Nursing Home Care Services Covers
Covered services include:
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Skilled nursing care
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Physical therapy
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Occupational therapy
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Speech-language pathology services
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Medical social services
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Nutritional counseling
What Are Skilled Care Services?
Skilled care services refer to medically necessary services that can only be provided by trained professionals, such as registered nurses or physical therapists. These services are typically used to treat a specific medical condition and require a certain level of training and expertise.
In the case of Medicare coverage for Texas nursing home costs, skilled care services would include things like wound care, IV therapy, and rehabilitation services. These types of care are essential for individuals who have recently had a hospital stay or are recovering from an illness or injury.
It's important to note that Medicare will only cover these skilled care services if they are deemed medically necessary and are provided in a Medicare-certified facility. This means the facility must meet certain quality standards set by Medicare for their services to be covered.
Limits of Medicare Coverage in a Nursing Home in Texas
Medicare's coverage is limited in both time and scope. After 20 days of covered skilled nursing facility care, a co-payment is required unless you have a health insurance policy that covers the co-payment. For days 21-100, beneficiaries are responsible for a daily co-payment. After 100 days, Medicare coverage ends entirely for that benefit period, leaving the patient responsible for all costs.
Medicare Does Not Cover Long Term Care Costs
Unfortunately, Medicare does not cover long-term care services such as custodial care, which involves assistance with daily activities like bathing and dressing. This type of care is typically provided in nursing homes but is not considered medically necessary by Medicare.
If you or a loved one needs skilled care in a Texas nursing home, it's important to understand the coverage limitations and requirements set by Medicare.
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It may also be helpful to work with an experienced elder law firm - us!- who can help navigate the complex system and ensure that all necessary documentation and criteria are met for coverage.
The Medicare 20-Day Rule For Skilled Nursing Care
The first 20 days of qualifying skilled nursing facility care under Medicare is fully covered, provided all eligibility criteria are met. This "Medicare 20-Day Rule" is critical for families planning financially for short-term rehabilitation needs.
After the first 20 days, who pays highly depends on multiple factors.
Who Pays for Nursing Home Care, Medicare or Medicaid?
While Medicare offers limited coverage for short-term, skilled care, Medicaid is the primary payer for long-term nursing home care for those who qualify. Medicaid in Texas covers nursing home care for eligible low-income seniors and individuals with disabilities. To qualify, one must meet specific income and asset criteria.
Get Approved For Medicaid And Pay For Nursing Home Care: Contact Us
Understanding the nuances of Medicare and Medicaid coverage for nursing homes in Texas is essential for planning long-term care for yourself or a loved one. While Medicare provides some benefits for short-term stays, Medicaid is often the solution for extended care needs.
To explore your specific situation and options, consulting with an experienced elder law attorney familiar with Texas regulations is a wise step.
Remember, preparation and knowledge are key to ensuring the best care and financial planning for the future.