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Medicare Testing Payment Options that affect Limited Nursing Home Coverage

Medicare is presently allowing pilot projects across the country to determine if it can reduce costs and improve quality of care pursuant to a provision under the Affordable Care Act. At the present time, Medicare coverage for skilled nursing care is limited to patients who spend three days and nights in a hospital and is limited to 20 days full payment by Medicare and generally up to 80 days co-payment (which is one reason why many have Medicare supplement policies). However, if the patient is re-admitted to the hospital shortly thereafter, then the hospital faces a fine by Medicare. As a result, many hospitals across the country (including Texas) do not formally “admit” the patient to the hospital. Instead the patient is placed under “observation” status so that the hospital reduces the risk of being fined. The problem with that is if the patient goes to a nursing home, then they will have to pay privately for their nursing home coverage unless the patient applies and is qualified for Medicaid which covers such care only if the patient meets certain financial and other requirements. The idea of the pilot programs is to see if hospitals (and other health care providers) can eliminate the three day rule and still reduce costs and improve the quality of care.

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