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It’s that time of year again where everyone is gearing up for the Annual Enrollment Period in October and seniors have a lot of questions. One question always comes up because for whatever reason is not explained in detail. “Does Medicare reset after 100 days?”

Your benefits will reset 60 days after not using facility-based coverage. This question is basically pertaining to nursing care in a skilled nursing facility. Medicare will only cover up to 100 days in a nursing home, but there are certain criteria’s that needs to be met first. 

skilled nursing

First and foremost, your stay and condition must be defined as “medically necessary” and ordered by a physician. Your care must be performed by skilled personnel such as a physical therapist, respiratory therapist, occupational therapist, etc. You have a qualifying hospital stay, your doctor has determined that you need daily care given by, or under the direct supervision of, skilled nursing or rehabilitation staff.

Medicare pays benefits for skilled nursing care only. It will not cover you for less specialized care such as intermediate care or custodial care.

The Medicare patient must have spent three overnights as an admitted hospital patient, stays such as “observation” stays would not qualify as admittance to a hospital and do not count toward the 3-day requirement.

The patient must be admitted to a Medicare participating facility and must be admitted within 30 days of hospital discharge. Also, the patient must be admitted for the same condition for which they were hospitalized. If all these conditions are met, Medicare will cover the first 20 days with no charge to the Medicare recipient.

If the patient requires further care after the 20th day, the patient will have a co-pay, days 21 to 100 which is usually picked up by having purchased a Medicare supplement plan. If you do not have a supplement plan a BGA agent can help assist you in purchasing the right one for your needs.

Medicare pays benefits for home health care only if the home health agency caring for you must be Medicare-certified. Your doctor must certify that you’re homebound and you must be under the care of a physician while receiving services under a plan of care established and regularly reviewed by a doctor.

Now that we’ve covered the reset days as far as post hospital care another question that is always asked is “How many days does Medicare allow in hospital?”

Now this is the part of Medicare that is known as Part A, the hospital portion of Medicare. Original Medicare will cover the Medicare recipient up to 90 days in a hospital per benefit period. Medicare Part A offers an additional 60 days of coverage with a high coinsurance, again however this high coinsurance is covered by purchasing a Medicare supplement policy.

These 60 reserve days are available to you only once during your lifetime. However, you can apply the days toward different hospital stays depending on the length of time you spend in the hospital during those stays.

Let me mention something very important that needs to be mentioned. Everything I just stated prior regarding Medicare Part A and Skilled Nursing Care is only applied under “Original” Medicare. If a beneficiary is covered under a Medicare Advantage Plan (Medicare Part C) the actual benefits may vary in terms of co-pays and coverages.

All contracts and benefits under these HMO’s and PPO’s vary. Again you should consult a BGA agent for these details.

BGA Insurance Group can offer consulting and retirement advice for seniors located in Pennsylvania, New Jersey, Delaware, South Carolina, North Carolina and Florida.