We may find ourselves, as caregivers, needing to find an out-of-home placement for our loved one following a hospital stay. We need to know how Medicare covers this skilled care or long-term (custodial) care depending on the need.
Medicare does cover 100 days of skilled care if every day is medically necessary. Rarely do skilled care patients meet this threshold for the entire 100 days.
CMS (Centers For Medicare and Medicaid Services) states, “A patient must receive skilled services five days a week based on a care plan with goals developed on admission. You are no longer eligible for skilled care when:
- skilled services are no longer required,
- the patient cannot tolerate five days a week,
- or you have met your goals.”
The average number of skilled care days per patient, based on Medicare claims data, is 28 days. As beneficiaries, we need to be aware we may be looking for a long-term-care living situation sooner rather than later.
That said, we need to understand the terms. CMS states, “long-term care (LTC) is for a beneficiary who needs someone to help them with their physical or emotional needs for an extended period of time. There are two types of LTC: custodial care and skilled care.
CMS defines Custodial Care as, “any non-medical care that can be reasonably and safely provided by non-licensed caregivers.”
Custodial Care is synonymous with Nursing Home, Assisted Living, or Long-Term Care facility. Typically, board and room are provided that includes “Activities of Daily Living (ADLs). CMS defines ADLs as, “activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.”
In addition, most Custodial Care facilities offer a gamut of activities, transportation, medical care, etc. Custodial Care is not covered by Medicare. Keep in mind, in Custodial Care, you may still need some sort of skilled therapy like PT, OT, wound care, etc. Custodial Care facilities most likely offer this skilled care under Part B coverage.
Some facilities have both skilled and non-skilled (Custodial) beds. The Skilled designation is a Medicare and Medicaid category with specific requirements. However, non-skilled facilities, or units, can modify the types of care they offer. Usually, the type of care offered is based on the number of nursing staff and the physical space available. Also, these Custodial Care facilities do not have to accept everyone. Hospitals do but not care homes. Admission decisions are based on staffing and patient needs.
The best way to find a nursing home (Custodial Care) will be based on the ADL, therapy, and social needs.
When choosing a home in a Custodial Care facility, consideration should be given to our loved one’s comfort. The choices range from a smaller facility where you know everyone or a larger resort-type facility with numerous amenities.
Regardless, we need to think about these choices before we need them. We need to visit facilities, discuss pricing and evaluate social interactions. Preparation is key to a successful move.
Most states have a Department of Insurance (DOI) with a number of brochures, including “Your Guide to Choosing a Nursing Home or Other Long-Term Services & Supports.” It may also be available at Area Agency on Aging. We can also request the brochure on-line from our state DOI.
Keep in mind, if the placement doesn’t work out, you can find another facility. The placement needs to work for your loved one AND for you. It seems overwhelming, but you can do it.
written by Wanda Cantrell, RHIA, CCS, CCS-P, LPN
This column is based on Medicare guidance and reflects the views of the writer.
Leave a Reply