HLTH 1005 Week 1 Surprise Discussion Post Example

Week 1 Discussion: Initial Post

I Assumed Medicare Paid for Nursing Homes: What the Rule Actually Says About Skilled Nursing Care and the Three-Day Stay

Before this week, I believed that once someone turned 65, Medicare would pay for a nursing home if they needed one. I had never checked. My grandmother moved into a nursing home two years ago, and I assumed Medicare was covering it, because that is what my family said when we talked about it.

The reading showed me what the rule actually is. Medicare Part A covers care in a skilled nursing facility only when the person needs daily skilled care, such as therapy or wound care that a licensed nurse or therapist must provide, and only after the person has been formally admitted to a hospital as an inpatient for three days or more (Centers for Medicare & Medicaid Services, n.d.). Even then, coverage is limited to 100 days in each benefit period, where days 1 through 20 carry no coinsurance and days 21 through 100 carry a set charge for each day. Care that is mainly help with bathing, dressing and eating, which is what most long-term nursing home residents need, is called custodial care, and Medicare does not pay for it when that is the only care someone needs.

The second surprise was the word inpatient. A patient who spends three nights in a hospital bed under observation status is an outpatient for Medicare purposes, and those nights do not count toward the three-day requirement (Centers for Medicare & Medicaid Services, n.d.). Two people in the same hallway, with the same illness, can end up with different coverage because of a status most patients never hear about.

So who pays for my grandmother? After asking my mother, I learned that her first few weeks were covered by Medicare after a hip fracture and surgery, and that she now pays from her savings and will likely need Medicaid when those run out. Our textbook describes Medicaid as the largest public payer for long-term care in the United States (Shi & Singh, 2022), which is the opposite of what I believed a week ago.

What I assumed: Medicare pays for nursing homes. What the rule says: Medicare pays for short-term skilled care after a hospital stay, and long-term custodial care falls mostly to families and Medicaid. What did you assume about who pays for something in your family's care, and were you right?

Reply to Marisol

Marisol, your post said you were surprised that hospitals have to treat everyone in the emergency room, and that you assumed this meant the care was free. I had the same idea. From what I read, the law requires a medical screening exam and stabilizing treatment regardless of ability to pay, but the hospital can still send a bill afterward (Shi & Singh, 2022). So the rule protects access to emergency care, not the patient's wallet. Did your reading say what happens to bills that patients cannot pay?

Reply to Desmond

Desmond, you wrote that you thought Medicare and Medicaid were the same program with two names. The Medicare & You handbook was useful for me here, because it describes Medicare as a federal program based mainly on age or disability and explains that Medicaid is a separate program run with the states and based on income (Centers for Medicare & Medicaid Services, 2024). My grandmother may end up on both, which I now know is called being dually eligible. That would have confused me completely last week.

References

Centers for Medicare & Medicaid Services. (n.d.). Skilled nursing facility (SNF) care. Medicare.gov. https://www.medicare.gov/coverage/skilled-nursing-facility-care

Centers for Medicare & Medicaid Services. (2024). Medicare & you 2025. U.S. Department of Health and Human Services. https://www.medicare.gov/medicare-and-you

Shi, L., & Singh, D. A. (2022). Delivering health care in America: A systems approach (8th ed.). Jones & Bartlett Learning.