Certified Revenue Cycle Representative (CRCR) Practice Exam

What factors can affect a Medicare beneficiary's eligibility for nursing care?

1. Age and income level

2. Type of health insurance policy held

3. Prior hospital stay duration and medical necessity

4. Geographical location

The correct answer is: Prior hospital stay duration and medical necessity

The eligibility of a Medicare beneficiary for nursing care is primarily determined by the requirement of medical necessity and the duration of a prior hospital stay. Medicare specifies that to qualify for coverage of skilled nursing facility care, a beneficiary must have had an inpatient hospital stay of at least three consecutive days (not counting the day of discharge). This rule emphasizes the importance of a prior hospital stay as a qualifying factor. Additionally, the concept of medical necessity plays a crucial role as well; Medicare covers nursing care if it is deemed medically necessary as part of a treatment plan for a condition that was treated during the inpatient stay. This means that the care provided in the nursing facility must be essential for improving or maintaining the health of the patient, which solidifies why these factors are integral to determining eligibility. The other factors presented, such as age and income level, type of health insurance policy, and geographical location, do not influence Medicare beneficiaries' qualification for nursing care as significantly as the combination of prior hospital stay duration and the requirement for medical necessity does.