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A legal question and answer column for seniors.

I always thought that Medicare pays for long term care in a nursing home. My friend has been in a nursing home for about 40 days and he says Medicare has stopped paying. What is going on?

Signed, Gus

It is a common misunderstanding that Medicare will pay for long term care in a nursing home. Typically, Medicare will only pay for a short period of time, after which the nursing home resident will either privately pay for his cost of care or will be eligible for Medical Assistance to pay for his cost of care.

If someone (who is eligible for Medicare and is enrolled in Medicare) has a 3-day qualifying stay at a hospital, and then transfers directly to a nursing home for rehabilitation, Medicare Part A will pay in full for the first 20 days, as long as the resident is receiving "skilled care" under the Medicare definition. Medicare will pay for a portion of the 21st through 100th day, as long as the resident continues to get skilled care. If the resident has a supplemental health insurance policy, the supplemental insurance policy should pay for the portion that Medicare does not pay. After the 100th day, Medicare and the supplemental health insurance policy will not pay for the care, even if the resident is still receiving skilled care.

Roughly speaking, skilled care means rehabilitative care, or care that is making the resident better. According to the Center for Medicare Advocacy, Inc., "skilled nursing and skilled rehabilitation services are those which require the skills of technical or professional personnel such as nurses, physical therapists, and occupational therapists. In order to be deemed skilled, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel." Custodial care does not qualify as skilled care.

Once the resident stops receiving skilled care, Medicare will stop paying. Once Medicare stops paying, the supplemental health insurance will also stop paying. If a resident disagrees with the decision that the resident is no longer receiving skilled care, the resident can ask the nursing home to submit a claim to the Medicare contractor for a second formal opinion. The resident does not have to pay until he receives the Medicare determination. If the resident disagrees with the formal Medicare determination, the resident can appeal, but generally must do so within 120 days of the initial determination.

It sounds to me like your friend has stopped receiving skilled care. This is a common scenario. If your friend goes back home for 30 consecutive days, he will be able to get another 100 day "spell of illness" coverage if he should find himself in the same situation again. Otherwise, if he stays in the nursing home, he will be spending his assets on his cost of care until he becomes eligible for Medical Assistance, unless he is already eligible.