What is A Nursing Home?

What exactly is a nursing home, and why do people consider it an option for care? 

Let’s explore this topic to illuminate the essential role nursing homes play in the continuum of senior care.

A nursing home, often referred to as a skilled nursing facility, is much more than just a place to live. It’s a comprehensive care environment designed to meet the various needs of its residents, ranging from long-term care for individuals seeking a home with full-time, higher-level care assistance to short-term rehabilitative care for those recovering from surgery, illness, or injury.

Why Do Seniors Go to Nursing Homes? 

The reasons are as diverse as the individuals themselves. For many, it’s the need for specialized medical care and support that can’t be adequately provided at home. This includes around-the-clock nursing care, access to physical therapy, occupational therapy, and other rehabilitative services designed to help residents regain their independence.

Short-Term Rehabilitation: 

After a hospital stay, seniors often require a level of care and rehabilitation that is best provided in a skilled nursing facility. Here, tailored rehabilitation programs help individuals recover strength, mobility, and functionality, serving as a bridge back to their daily lives.

Approximately one-fifth of nursing home residents are there for a duration of three months or less. Their stay is often necessitated by the need for skilled nursing, rehabilitation, or various therapy services over a brief period. Typically, these residents require care following a hospital stay due to conditions like infections, or after undergoing procedures such as hip replacement surgery, and may also include those in need of end-of-life care.

Long-Term Care:

Nursing homes offer a secure, caring environment for seniors facing chronic health issues or the realities of aging that require ongoing nursing care. The focus is on maintaining the highest possible quality of life, with attention to both medical and personal needs.

Some residents face chronic disabilities and require ongoing skilled nursing attention that is unfeasible to provide at home. Conditions such as the aftermath of a stroke might leave individuals unable to perform basic self-care tasks, including bathing, dressing, and eating.

Others may need constant oversight due to cognitive impairments like Alzheimer’s disease or mental health conditions such as severe depression, which impede their ability to live independently.

Challenges associated with dementia or certain mental health issues necessitate a level of care that includes supervision and assistance with daily living activities. This care is tailored to manage behaviors like aggression, wandering, or communication difficulties.

Respite Care:

Nursing homes also provide respite care, offering temporary relief for family caregivers. These short stays for seniors give their caregivers a much-needed break, knowing their loved one is in good hands.

It’s not uncommon for residents to experience multiple issues concurrently, with many needing support for cognitive impairments alongside assistance with daily living activities.

Is There More than One Kind of Nursing Home?

nurse helping woman into wheelchair

Nursing homes come in various forms, from standalone facilities dedicated solely to skilled nursing care to integral parts of Continuing Care Retirement Communities (CCRCs). CCRCs allow residents to transition smoothly between levels of care — from independent living to assisted living to skilled nursing — all within the same community.

Additionally, some hospitals feature skilled nursing units for those needing short-term care, blending hospital-grade care with a step toward home.

Does Florida Have Many Nursing Homes?

According to the Florida Agency for Health Care (AHCA), Florida has 691 licensed nursing homes in Florida, with approximately 85,000 beds. But at any given time, 85% of those beds are occupied. 

In contrast, there are almost 3,100 licensed assisted living communities in Florida, with more than 105,00 beds.

Are Nursing Homes Expensive?

Yes. By any standards, nursing homes and skilled nursing care can be expensive. 

According to Genworth Financial, the cost of a semi-private room in a nursing home in Cape Coral, Florida, in Lee County is a little more than $10,000 per month. The cost of a private room there is $14,900 per month or $178,000 per year.

In comparison, a room in assisted living in Cape Coral is about $5,500 per month.

Does Medicare Pay for Skilled Nursing?

medicare form with stethoscope and heart

Medicare pays some of the cost of skilled nursing. But it is important for seniors to understand what Medicare does and does not pay for.

According to the Centers for Medicare and Medicaid Services (CMS), Medicare is the largest single-payer for health care services in the U.S. In a single year, Medicare processes more than 1.1 billion claims from 1.5 million healthcare providers and pays more than $424 billion in Medicare payments.

You might think that with all that money being paid, your nursing home costs would be covered 100%. They are not. 

Medicare pays certain amounts for the first 100 days in skilled nursing, and after that, you are responsible for 100% of the costs. Below is a brief outline of what Medicare pays for at home, in assisted living, and in skilled nursing homes.

Medicare and At-Home Care

Many seniors can receive rehabilitative and other services at home. Here’s what Medicare Part B will typically cover at home:

  • Therapeutic Services:

Medicare provides coverage for physical, occupational, and speech therapy deemed necessary and reasonable for your medical condition under the guidance and prescription of a qualified therapist.

  • Home Health Aide Services:

For individuals receiving skilled nursing care, Medicare may fund certain home health aide services such as assistance with activities of daily living (ADLs) like bathing, dressing, and toileting on a limited, part-time, or intermittent basis.

It is important to note that Medicare does not extend coverage to round-the-clock home care, nor does it cover services purely related to daily living activities such as meal delivery, cleaning, and shopping when these are the sole services required.

  • Social Services:

Medicare may offer coverage for medical social services that address a patient’s illness’s social and emotional aspects, including counseling, support for well-being, and assistance in accessing community resources.

  • Durable Medical Equipment:

Medicare covers specific medical equipment deemed necessary for in-home use, such as wheelchairs, walkers, and hospital beds prescribed by a physician.

  • Medicare Part B at-Home Services:

Under Medicare Part B, coverage includes part-time or intermittent skilled nursing care, along with physical therapy, speech-language pathology, continued occupational therapy, and medical social services.

Medicare contributes 80% of the approved costs for these services after the beneficiary pays an annual deductible ($233 in 2024), leaving the beneficiary responsible for the remaining 20%. Services not covered include 24-hour home care, meal delivery, and homemaker tasks.

What About Medicare and Assisted Living?

nurse taking woman's temperature

It is crucial to understand that Medicare does not cover the expenses associated with assisted living facilities. Funding for assisted living typically comes from private payments, long-term care insurance, or Medicaid, subject to eligibility based on financial and health criteria.

Do You Qualify for Medicare Payments for Skilled Nursing Care?

Understanding your eligibility and the scope of coverage under Medicare is crucial. Medicare Part A, known for hospital insurance, provides coverage for skilled nursing care, contingent upon satisfying specific eligibility conditions. 

To be eligible for Medicare Part A’s skilled nursing care benefits, the following criteria must be met:

  • A preceding hospital stay of a minimum of 3 days, excluding the day of discharge.
  • A medical assessment by your doctor indicating the necessity for daily skilled nursing care.
  • The requirement for skilled nursing services must stem from a medical condition related to your hospital stay (such as an infection), treated during your initial 3-day hospital admission, irrespective of the primary reason for admission.

What Medicare Pays For in Nursing Homes

nurse helping man out of wheelchair

Medicare provides coverage for a range of services within skilled nursing facilities, including:

  • Accommodation in a semi-private room.
  • Provision of meals.
  • Nutritional guidance and counseling.
  • Care provided by skilled nurses.
  • Rehabilitation services such as physical and occupational therapy.
  • Prescription drugs.
  • Access to necessary medical supplies and equipment.
  • Support through medical social services, which may involve counseling.
  • Transport services via ambulance when required.

How Long Does Medicare Pay?

  • Days 1-20: Medicare Part A fully covers a semi-private room, meals, skilled nursing care, physical and occupational therapy, medications, and necessary medical equipment.
  • Days 21-100: Patients contribute up to $194.50 per day (as of 2024), with Medicare covering the remaining costs.
  • After day 100: Medicare provides no coverage, leaving patients responsible for all costs.

What Can You Do When Medicare Stops Paying?

Medicare is the US national health insurance program that seniors and many disabled individuals are entitled to under the Social Security Act. If Medicare or your Medicare plan does not pay for services, medicine, or treatments that you think you are entitled to, you have the right to appeal that decision.

The appeals process can be lengthy and extremely complicated. At Florida Senior Consulting, we deal with issues like this every day and can help guide you to the best resources for protecting your senior loved ones.

Should You File an Appeal?

senior couple talking to advisor

Initiating an appeal is your recourse if you find yourself at odds with a coverage or payment decision from Medicare or your Medicare health insurance plan. Reasons for an appeal might include:

  • A denial for coverage of healthcare services, supplies, items, or prescriptions you consider should be covered by Medicare.
  • A refusal of payment for healthcare services, supplies, items, or prescriptions you’ve already received.
  • Disagreements over the cost-share amount you’re being asked to pay for healthcare services, supplies, items, or prescriptions.

You also possess the right to appeal under circumstances such as:

  • A cessation or reduction by Medicare or your health insurance plan in the coverage or payment for healthcare services, supplies, items, or prescriptions you deem necessary.
  • Being impacted by a decision within a drug management program that limits your access to certain high-risk medications, including opioids and benzodiazepines.
  • A claim denial based on an existing accident record, regardless of the claim’s irrelevance to the actual accident.

Key Points to Remember When Initiating a Medicare Appeal

Seek Support: Collaborate with your doctor, healthcare provider, or equipment supplier to gather supporting evidence for your appeal.

  • Follow Written Instructions:

Your plan must provide detailed written instructions on how to file an appeal.

After filing, the plan reviews its initial decision. If the decision is still not in your favor, the case moves to an external review.

  • Gather Evidence:

Work closely with your physician, healthcare provider, or the supplier of your medical equipment to compile evidence that supports your appeal.

  • Accelerated Decision Request:

If a delayed decision poses a risk to your health, submit a request for an expedited review to your insurance plan.

If your healthcare provider or insurance plan agrees, they are required to issue a decision within 72 hours.

  • Adherence to Guidelines:

Your insurance plan is obligated to furnish clear, written guidelines on the appeals process.

Upon submission of your appeal, your plan reevaluates its prior decision. Should the outcome remain unfavorable, your appeal progresses to an independent external review.

  • Review Upon Early Hospital Discharge:

If you are facing what you believe to be a premature hospital discharge, you are entitled to request an immediate review from the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

During this review period, you are permitted to remain in the hospital at no additional cost, with the hospital barred from forcing your discharge before a decision is reached.

  • Expedited Appeals:

This process is specifically designed for those contesting the termination of services by skilled nursing facilities, home health agencies, or comprehensive outpatient rehabilitation facilities.

If you’re concerned about being discharged too early from a hospital, you have the right to an instant review by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

You can stay in the hospital without charge during the review, and the hospital cannot make you leave until a decision is made.

  • Fast-Track Appeals Process:

Available for disagreements with decisions to end services provided by skilled nursing facilities, home health agencies, or comprehensive outpatient rehabilitation facilities.

Medicare Appeals Specific to Nursing Homes

  • Rights to Appeal: 

Individuals residing in skilled nursing facilities possess the right to challenge decisions regarding premature discharge or the cessation of Medicare coverage for their stay.

  • Obligation to Notify: 

Skilled nursing facilities are required to issue a written notification to residents about any impending discharge. This notice should detail the reasons for the discharge, specify the discharge date, and provide guidance on how to contest the decision.

  • Accelerated Review Process:

Residents facing discharge from a skilled nursing facility have the option to seek a swift review of the discharge decision through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), mirroring the process for hospital discharges.

  • Stay at No Charge During Appeals: 

Residents appealing their discharge can remain in the facility without incurring charges during the appeal process. Facilities are prohibited from ejecting residents until a determination has been made by the BFCC-QIO.

  • Evaluation by BFCC-QIO:

In reviewing an appeal, the BFCC-QIO examines the resident’s medical records, consults with healthcare providers, and evaluates the grounds for the appeal to decide if the discharge is justified or if Medicare coverage should be extended.

Have Questions About Nursing Homes?

nurse and senior man high fiving

At Florida Senior Consulting, we understand that transitioning your senior loved one to a skilled nursing facility may be the most critical decision you make regarding their quality of life and health care. 

We understand the best ways to afford memory care, assisted living, independent living, and nursing homes. 

Let us help you and your family with these difficult decisions.

As a Florida-based company with expert knowledge of the Florida senior market, we help seniors and their families navigate these options daily.

We have certified staff, licensed nurse advocates, and decades of experience in the field. And 100% of our employees are Certified Dementia Practitioners.

Call us, and we will answer all your questions and help you decide what is best for your family and your senior loved one.

For peace of mind, call us at (800) 969-7176 or visit FloridaSeniorConsulting.com.

Senior living on your terms. The choice should be yours.

Contact Florida Senior Consulting

(800) 969-7176