When Medicare will no longer cover your loved one’s stay in a nursing home or skilled nursing facility, you have three options for the next step. You can appeal the Medicare denial, explore alternative payment options such as Medicaid, private pay, or long-term care insurance, or consider moving your loved one to a lower level of care or at-home care. To allow your loved one to maintain their quality of life and find appropriate support, it’s essential to plan early for how they’ll pay for the care they need once they’ve received a Notice of Medicare Non-Coverage, or NOMNC.
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As a health insurance program, Medicare isn’t designed to pay for long-term custodial care. Medicare will only pay for short-term stays of 100 days or less, such as for rehabilitation after an injury or illness. Eligible recipients must receive care in a Medicare-certified nursing home or skilled nursing facility that:[01]
A Place for Mom’s Niki Gewirtz, who has more than two decades of experience managing residential care communities, explains: “We might talk with a family whose loved one went to rehab after surgery, but they couldn’t do any therapy that required weight bearing. Since they couldn’t really participate in therapy, they couldn’t improve. In a case like that, Medicare won’t keep paying for a nursing home stay if the person isn’t getting better.”
When someone no longer meets these criteria, Medicare will stop paying for their stay. At that time, federal law requires the nursing home or skilled nursing facility to provide them with a Notice of Medicare Non-Coverage (NOMNC) within 2 calendar days of the planned discharge date. While facilities may provide the notice in person or over the phone, they must also provide it in writing.[02]
If your loved one has received a NOMNC letter, you have three options for ensuring they can continue to receive the care they need:
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If you and your loved one feel that they should still receive care at the nursing home and they still meet the criteria above, they can file an appeal. The State Health Insurance Assistance Program in your loved one’s area can help with the process. There are two kinds of appeal: fast and standard.
A fast Medicare appeal must be filed by noon on the day before your loved one’s care is scheduled to end. Medicare has two days after your loved one’s care is scheduled to end to decide whether it will continue to pay for their nursing home stay. Your loved one can stay in the nursing home while the appeal decision is pending as long as the appeal was filed no later than the day they’re scheduled to be discharged.
If you can’t file a fast appeal, you can file a standard appeal within 60 days. Your loved one can stay in the nursing home while the appeal is being considered, and Medicare must decide within 30 days.
If Medicare won’t pay for your loved one’s continued stay in the nursing home, and you and they decide they should stay, they’ll need to use another method to pay, such as private funds or VA benefits.
When a loved one leaves a nursing home, they can continue living in a supportive environment, whether that’s at home or in a senior living community. What’s best for them depends on their unique needs.
If your loved one has received a NOMNC letter, you have three options for ensuring they can continue to receive the care they need:
For older adults who need help with ADLs, an assisted living community or a residential care home are supportive options.
“In the case of someone who needs a little more time to recover before they can continue with physical therapy and eventually go home, a short stay in assisted living or a place equipped to do two-person transfers can get them on their way to recovery,” Gewirtz explains.
For those who need specialized care related to a diagnosis of Alzheimer’s disease or other type of dementia, memory care communities offer safety and security.
Gewirtz recommends working through options early. “If the ideal scenario of Mom going home doesn’t happen, what’s the next step?” she asks.
“When you’re in communication with your loved one’s therapy team, physician, case manager, and others, and if you know what your loved one’s resources are, you’re already ahead. If Mom wants to go home but she can’t, you’re her best advocate when you’re prepared with a plan,” Gewirtz explains.
It’s common for seniors to wish to remain within the comfort of their own home as they age. With the help of home care and home health care, your loved one can continue to live in familiar surroundings.
If your loved one doesn’t need assistance with activities of daily living, or ADLs, they may thrive in a 55+ community setting, which could be senior apartments or independent living. If they were discharged from the nursing home with orders for occupational or physical therapy, Medicare will cover the cost of these medically necessary services. Some independent living communities allow home health care services on-site, even though they do not provide these services themselves.
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“We talk with lots of families about the importance of being aware: of their loved one’s financial picture, their health status, their insurance plans, and what the care options are. It’s very common for us to talk with families that are in crisis because something changed quickly and they just weren’t prepared for what came next,” Gewirtz says.
Finding the care for your loved one’s unique needs following a stay in a skilled nursing facility or nursing home can be a challenge. You don’t have to do it alone. The knowledgeable Senior Living Advisors at A Place for Mom can assist you with locating senior care options outside of skilled nursing — all at no cost to your family.
Medicare providers — including nursing homes, hospitals, and others — are required by law to give a Notice of Medicare Non-Coverage at least 2 days before care in that facility is expected to end. The notice should include the date care is scheduled to end.
Yes, a nursing home can discharge someone for non-payment. However, the patient must be informed in writing least 30 days before they’re discharged. If your loved one has received a notice of discharge, the long-term care ombudsman in their area can help.
Centers for Medicare & Medicaid Services. Skilled nursing facilities. Medicare.gov.
Centers for Medicare & Medicaid Services. Your protections. Medicare.gov.
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