The difference between Custodial Care and Skilled Nursing Care under Medicare

Long-term care (LTC) is intended for individuals who require extended assistance with their physical or emotional needs. There are two distinct types of LTC: skilled care and custodial care. Skilled care involves specialized nursing or rehabilitative services administered by licensed healthcare professionals such as nurses and physical therapists, as prescribed by a physician. Custodial care, on the other hand, comprises the routine assistance typically provided by aides and other support staff.

What Is a Long-Term Care in Medicare?

Long-term care costs are usually the responsibility of the patient, but some limited coverage may be available. Medicare may pay for a short-term stay in a skilled nursing facility if certain requirements are met. Hospice care is always covered by Medicare Part A for patients with a terminal illness who do not seek further treatment. However, custodial care may not be covered by Medicare.

The criteria for becoming eligible for long-term care under Medicare while hospitalized are as follows:

Firstly, you need to be an admitted inpatient in a hospital approved by Medicare for at least three days. Secondly, within 30 days of your inpatient hospitalization, you must be admitted to a nursing facility certified by Medicare. Additionally, you must require extra therapy, like physical or occupational therapy. Finally, your medical condition must necessitate skilled nursing services.

Once you meet these requirements, you become eligible for Medicare long-term care, which covers a maximum of 100 days during each benefit period.

Will Medicare Pay For Long-Term Care?

Medicare provides coverage for inpatient hospital care through Part A, but it does not offer long-term care coverage, with a few exceptions.

Once you exhaust your lifetime reserve days, Medicare will stop covering the cost of long-term care, and you will be accountable for all expenses. Although there are other programs that can assist with costs. For example, Medicaid offers aid to low-income individuals and families to help with healthcare expenses and is the largest payer in the nation for long-term and nursing home care.

Furthermore, purchasing long-term care insurance can be another option to consider. These policies offer coverage for extended periods, and the benefits provided depend on the specific policy.

What Is a Custodial Care in Medicare?

Long-term care goes beyond medical services and encompasses a wide range of services. It is not only restricted to nursing homes, and it is not just for sick people. Many individuals require long-term care services for custodial needs.

Custodial care involves providing assistance with daily living activities, such as bathing, grooming, dressing, and other tasks. Non-medical professionals administer these services, and they are designed to maintain and improve a person’s quality of life while compensating for the loss of independent physical or mental functioning. Homemaker services may be provided to prevent the need for nursing facility care.

Custodial care providers may not have medical or nursing training but are responsible for providing non-medical services such as cooking, cleaning, and shopping. These services aim to preserve an individual’s health, prevent deterioration, and enhance their quality of life. While custodial care is usually provided by family or friends, it can also be offered by licensed health aides or unlicensed individuals.

Custodial care can be delivered in the home, residential facilities, or community care centers, and is provided by unlicensed or licensed health aides, certified nursing assistants, or family and friends. Custodial care facilities are referred to by various names and offer varying levels of skilled care, but most patients receive custodial care.

What Is a Skilled Nursing Facility Care?

A skilled nursing facility is a specialized medical center where licensed healthcare professionals such as nurses, physical and occupational therapists, speech pathologists, and audiologists provide essential medical services to in-patients who require rehabilitation or medical treatment. Patients in these facilities receive around-the-clock assistance with activities of daily living (ADLs) and medical care, and federal regulations strictly govern what these facilities can and cannot do.

Upon admission to a skilled nursing facility, patients undergo an initial health assessment, and ongoing health assessments are conducted to monitor their physical and mental health, medication needs, and ability to perform ADLs such as bathing and dressing. It is essential to note that skilled nursing facilities and nursing homes cannot discriminate against patients based on protected characteristics such as race, age, sex, ethnicity, or religion. In cases where discrimination occurs, patients or their families can report the incident to relevant authorities such as state nursing home regulatory agencies or long-term care ombudsmen.

Medicare coverage for Skilled Nursing Facility services has specific guidelines that must be followed. Skilled nursing services are provided by healthcare employees like physical therapists, nursing staff, pathologists, and physical therapists. The guidelines require doctor-ordered care from certified healthcare employees to treat current or new conditions. To qualify for Medicare coverage, beneficiaries must have been an inpatient in a hospital facility for three consecutive days and go to a Medicare-certified Skilled Nursing Facility within 30 days of hospital discharge. Additionally, beneficiaries must meet the 3-day rule, which requires a medically necessary inpatient stay of three consecutive days in a hospital facility, excluding outpatient observations and emergency room visits. However, exceptions to this rule apply if the patient’s health conditions are not appropriate for placement in a nursing facility or if the patient requires around-the-clock nursing services.

Difference Between Skilled Nursing Facility Care and Custodial Care

Custodial care refers to non-medical care that can be safely provided by non-licensed caregivers and can occur at home or in a nursing home. This type of care assists with daily activities like bathing and dressing, and can also involve help with household tasks like cooking and laundry. Medicaid may cover custodial care in nursing homes, but not in home settings.

Skilled care pertains to essential medical attention that necessitates the expertise of skilled or licensed healthcare professionals or requires their close supervision. It can be more expensive than custodial care and can take place at home or in a skilled nursing facility. Examples of skilled care include physical therapy, wound care, intravenous injections, and catheter care. Medicaid may cover skilled care, but each state’s program has different rules regarding when it is considered medically necessary and eligible for coverage.

Custodial care vs. Skilled Nursing Facility Cost

Medicare usually does not provide coverage for custodial care, unless it involves medical care that is part of a skilled nursing facility. Additionally, Medicare offers coverage for up to 100 days of care in a skilled nursing facility, provided that the individual seeking care is admitted within 30 days of discharge from a hospital, and the condition or illness is related to the hospital stay.

The cost of custodial care is impacted by several factors including the time needed for care, the location of care, the method of hiring, the city of residence, and specialized care needs. The type of care, whether it is in-home care, adult day care, or assisted living care, affects the cost. Hiring a caregiver through an agency may cost more but provides qualified caregivers. Specialized care needs for conditions like memory disorders or mobility issues may also increase the cost of custodial care.

Medicare Part A provides coverage for a limited number of days in a Skilled Nursing Facility (SNF) for beneficiaries who meet certain requirements. Specifically, Part A benefits cover up to 20 days of care in an SNF for beneficiaries who are admitted to the facility within 30 days of a qualifying hospital stay. After the first 20 days, beneficiaries are required to pay a coinsurance amount for each day up to an additional 80 days. Once the beneficiary has received SNF care for a total of 100 days, their SNF benefits are exhausted, and they must pay for all care costs themselves, except for some Part B health services.

It is important to note that benefit periods determine how SNF coverage is measured. A benefit period begins on the first day that the beneficiary is admitted to an SNF on an inpatient basis and ends when the beneficiary has not been an inpatient in an SNF or hospital for 60 consecutive days. A new benefit period may begin once the prior benefit period ends, and the beneficiary receives another admission to an SNF.

There are some unique billing situations for SNF care that beneficiaries should be aware of. For example, if a beneficiary is discharged from an SNF and then readmitted within 30 days, this is considered a readmission. Another instance of readmission is if a beneficiary requires new care within 30 days after the first non-coverage day. In such cases, Medicare may require a claim, even if payment is not required.

Additionally, if a beneficiary exhausts their SNF benefits, the monthly bills continue with normal submission, but the beneficiary must still be in a Medicare facility. Full exhaustion means that the beneficiary does not have any available days on their claim, while partial exhaustion means that the beneficiary still has some available benefit days on their claim.

There are also specific billing situations for other types of facilities. For example, if a beneficiary needs SNF care but does not have a qualifying hospital stay, they may be able to receive coverage if they remain in the SNF for at least one night and receive covered care on the second night.

Beneficiaries can appeal health service terminations if they believe that their care is being terminated prematurely due to coverage reasons. In such cases, providers can expedite the determination process to ensure that beneficiaries receive a timely review of their appeal.

Overall, it is important for beneficiaries to understand the limitations and requirements of Medicare’s SNF coverage to ensure that they receive the care they need while minimizing their out-of-pocket costs.

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