Medicare Coverage of Skilled Nursing Facility Stays
Medicare Part A will cover part of your stay in a skilled nursing facility if you meet a number of requirements.
A growing number of patients recovering from surgery or a major illness are referred by their doctors to skilled nursing facilities. These facilities provide an important, less expensive alternative to hospitalization.
Medicare Part A may cover some of your costs of staying in a skilled nursing facility (SNF), but strictly limits how much it will pay.
What Is Skilled Nursing Care?
Skilled nursing facilities are sometimes called post-acute rehabilitation centers, but the rules for a stay in an acute care rehabilitation center, or inpatient rehab facility (IRF), are different. For more information, see our article on Medicare coverage of inpatient rehab facility stays.
Skilled nursing facility care, which takes place in a hospital’s extended care wing or in a separate nursing facility, provides high levels of medical and nursing care, 24-hour monitoring, and intensive rehabilitation. It is intended to follow acute hospital care due to serious illness, injury, or surgery—and usually lasts only a matter of days or weeks.
In contrast, most nursing homes provide what is called custodial care—primarily personal, nonmedical care for people who are no longer able to fully care for themselves. Custodial care often lasts months or years, and is not covered at all by Medicare. For the most part, custodial care amounts to assistance with the tasks of daily life: eating, dressing, bathing, moving around, and some recreation. It usually involves some health-related matters: monitoring and assisting with medication and providing some exercise or physical therapy. But it is ordinarily provided mostly by personnel who are not highly trained health professionals and does not involve any significant treatment for illness or physical condition.
(Medicaid will pay for unskilled nursing home care for people with low income and assets. For more information, read our article on when Medicaid will pay for a nursing home or assisted living.)
Requirements for Medicare to Cover Skilled Nursing Facilities
You must meet two requirements before Medicare will pay for any nursing facility care. You must have recently stayed in a hospital, and your doctor must verify that you require daily skilled nursing care.
Medicare used to require that your condition be expected to improve, but now Medicare will pay for skilled nursing care if it's needed to maintain your condition or to slow deterioration of your condition.
Prior Hospital Stay
Your stay in a skilled nursing facility must follow at least three consecutive days, not counting the day of discharge, in the hospital. And you must have been actually "admitted" to the hospital, not just held "under observation."
In addition, your stay in the nursing facility must being within 30 days of being discharged from the hospital. If you leave the nursing facility after coverage begins, but are readmitted within 30 days, that second period in the nursing facility will also be covered by Medicare.
Requiring Daily Skilled Nursing Care
Your doctor must certify that you require daily skilled nursing care or skilled rehabilitative services. This care can include rehabilitative services by professional therapists, such as physical, occupational, or speech therapists, or skilled nursing treatment that require a trained professional, such as giving injections, changing dressings, monitoring vital signs, or administering medicines or treatments. This daily care must be related to the condition for which you were hospitalized.
If you are in a nursing facility only because you are unable to feed, clothe, bathe, or move yourself, even though these restrictions are the result of your medical condition, you are not eligible for Medicare Part A coverage. This is because you do not require skilled nursing care as defined by Medicare rules. However, if you require occasional part-time nursing care, you may be eligible for home health care coverage. For more information, see our article on Medicare's home health coverage.
What Skilled Nursing Services Will Medicare Cover?
The nursing facility care and services covered by Medicare are similar to what is covered for hospital care. They include:
- a semiprivate room (two to four beds per room), or a private room if medically necessary
- all meals, including special, medically required diets
- regular nursing services
- special care units, such as coronary care
- drugs, medical supplies, treatments, and appliances provided by the facility, such as casts, splints, wheelchair, and
- rehabilitation services, such as physical therapy, occupational therapy, and speech pathology, provided while you are in the nursing facility.
Costs for staying in a skilled nursing facility for the first twenty days are covered 100%; after that, there is a co-pay (see below).
What Will Medicare Not Cover?
Medicare coverage for a skilled nursing facility does not include:
- personal convenience items such as television, radio, or telephone
- private duty nurses, or
- a private room when not medically necessary.
How Much of the Cost Does Medicare Cover?
Despite the common misconception that nursing homes are covered by Medicare, the truth is that it covers only a limited amount of inpatient skilled nursing care. For each spell of illness, Medicare will cover only a total of 100 days of inpatient care in a skilled nursing facility, and then only if your doctor continues to prescribe skilled nursing care or therapy.
For the first 20 of 100 days, Medicare will pay for all covered costs, which include all basic services but not television, telephone, or private room charges.
For the next 80 days, the patient is personally responsible for a daily copayment, and Medicare pays the rest of covered costs. In 2013, the copayment amount is $148; the amount goes up each year.
After 100 days in any benefit period, you are on your own as far as Medicare Part A hospital insurance is concerned. (Lifetime reserve days, available for hospital coverage, do not apply to a stay in a nursing facility.) However, if you later begin a new spell of illness (called a benefit period), your first 100 days in a skilled nursing facility will again be covered. For more information on benefit periods and lifetime reserve days, see our article on Medicare Part A coverage.
by: Attorney Joseph Matthews