Does Medicare Cover Skilled Nursing Facility Care?

Key takeaways

  • Skilled nursing facility (SNF) care is covered by Original Medicare Part A if it’s for a hospital-related medical condition.

  • It must be in a Medicare-certified SNF or nursing home.

  • Up to 100 days of skilled nursing facility care are covered per benefit period, but only up to 20 days are covered at 100% by Original Medicare.

  • Medicare coverage for skilled nursing facilities care is subject to being discharged from an inpatient hospital stay of at least three nights.

  • You must wait for a new benefit period to renew your SNF (nursing home) care.

  • Long-term care is not covered by Medicare if you need skilled nursing for over 100 days.

  • Most Medigap plans offer full health coverage (including coinsurance) for up to 100 days of skilled nursing care per benefit period.

What Are Skilled Nursing Facilities?

Skilled nursing facilities (SNF) are residential facilities that provide round-the-clock medical care and assistance to individuals who require specialized care to recover from their medical condition or physical limitations.

This is different than nursing homes, which focuses on long-term care. Nursing homes are for long-term care. A skilled nursing facility is a temporary residence for recovery or rehabilitation.

Skilled nursing facilities are typically recommended for individuals who require a higher level of medical care and assistance than can be provided in a home setting or assisted living facility. These individuals may include those with chronic medical conditions, those recovering from surgery or an injury who need more help[ to recover than what is available in their home setting.

What Are the Common Conditions that Require Skilled Nursing Facility (SNF) Care?

You might require SNF for the following medical condition:

  • respiratory disorders

  • neurological disorders

  • diabetes

  • complex wound care, such as pressure ulcers or surgical wounds

  • cancer

  • pneumonia

  • septicemia

  • kidney and urinary tract infections

  • heart failure or heart disease

  • renal failure

  • hip and femur procedures, aside from joint replacement

  • joint replacement

  • COPD

  • shock

In Which Cases Does Medicare Pay for Skilled Nursing Care?

According to Medicare.gov, you’ll get Medicare coverage for a skilled nursing facility stay if all of the following conditions are met:

1) You have Medicare Part A (Hospital Insurance) and have days left in your benefit period available to use.

2) To qualify for skilled nursing care, you need to have spent 3 consecutive days in a hospital as an inpatient where you were formally admitted for medically necessary reasons. This is often called the three-midnight rule. It must be a qualifying hospital stay, not simply under observation. Time spent in observation or the emergency room doesn’t count. You must be admitted to the skilled nursing facility within a short time (normally, 30 days) after the initial hospital stay.

If you return to a skilled nursing facility within 30 days of leaving, you may not need another 3-day inpatient hospital stay to receive additional benefits.

3) You require, and your doctor has ordered, inpatient services in a SNF, under the supervision of professional therapy staff or hospital staff like doctors, registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, or audiologists.

4) You must receive daily skilled nursing care, which can only be given while you’re an inpatient at a skilled nursing facility. If you’re receiving skilled therapy services, daily care is considered necessary if the therapy is provided 5-7 days a week.

5) You require skilled services for either an ongoing condition that was treated during your 3-day hospital stay (where you were admitted as an inpatient) or a new condition that developed while receiving SNF care for the ongoing condition.

6) SNF services must be reasonable and medically necessary for the diagnosis or treatment of your specific, hospital-related medical condition.

7) It must be a Medicare-certified SNF.

8) Transportation to and from medical appointments outside the SNF are covered.

How Long Does Medicare Cover Skilled Care Facilities?

Medicare tracks your SNF benefits in a benefit period that begins on the day you receive inpatient hospital or SNF care, and lasts for up to 100 days.

Once you’ve used up the 100 days in a SNF, you need to wait until the benefit period ends before renewing your SNF benefits. The benefit period ends after 60 consecutive days without SNF or hospital care.

If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins.

There’s no limit to the number of benefit periods you can have, but you must meet Medicare’s requirements and have another 3-day qualifying hospital stay to renew your SNF benefits after a benefit period ends.

What Skilled Care in a SNF are Covered by Medicare?

Medicare Part A will cover:

  • A semi-private room (a room you will share with other patients; unless a private room is medically necessary)

  • Medications

  • Meals

  • Dietary counseling

  • Medical social services

  • Skilled care and skilled services

  • Medical supplies and equipment used in the facility

  • Ambulance transportation (if you can’t safely receive therapy in another method of transportation) to the closest supplier of medically-necessary services that aren’t available at the SNF, including the return trip.

Medicare will also cover physical therapy, occupational therapy, and speech therapy if you require them to meet your specific health goal. A health goal varies from patient to patient.

Are Prescription Drugs in SNF Covered by Medicare?

Yes, Medicare Part A (inpatient services) covers prescription drugs that are administered during a Medicare-covered stay in a SNF, such as drugs that are given through an IV or injected. These drugs are typically included in the SNF’s daily rate, and the SNF is responsible for providing them.

Medicare Part D, on the other hand, covers prescription drugs that are dispensed by a pharmacy and taken orally, such as pills and capsules.

What is Not Covered by Medicare?

  • Extra telephone or television charges not covered by the SNF

  • Private-duty nursing services provided

  • Various personal items like razors, toothpaste, and other personal hygiene items

How Much Do Skilled Nursing Facility Services Cost with Medicare?

With Medicare Part A, skilled nursing facility costs as of 2023 are the following:

  • Days 1–20: You pay zero for covered services and Medicare pays for everything.

  • Days 21–100: You pay a $200 per day coinsurance for covered services.

  • Days over 100: You are responsible for the full cost of services. Medicare coverage stops.

Are There Any Additional Rules for Skilled Nursing Facilities?

Beware that your doctor might order additional services on your behalf that aren’t usually covered by Medicare Part A. Avoid unexpected costs by communicating well with your doctor and plan provider.

Long-term care, like custodial care or assisted living care is not a part of Medicare-covered services.

If a beneficiary in a SNF needs medical services that are covered under Medicare Part B, such as physical therapy or certain medical supplies, those services may be covered separately under Part B. However, the actual stay in the SNF itself is not covered by Medicare Part B.

Does Medicare Cover Inpatient Rehabilitation Care?

Yes, Medicare also covers rehabilitation services that are similar to SNF but provide intensive rehabilitation, continuous medical care, and coordinated care from your doctors and therapists.

Usually, it’s a type of intensive care after the injury that had affected multiple systems within the body. In this case, Medicare covers the same services as for SNF and doesn’t cover the same items as mentioned above.

However, keep in mind that the amount of coverage for inpatient rehabilitation care (IRC) is different from skilled nursing care.

According to Medicare.gov, the costs are the following:

  • Days 1-60: $1,600 deductible applies

  • Days 61-90: you pay a $400 copayment each day

  • Days 91 and over: An $800 copayment each “lifetime reserve day” after day 90 (up to a maximum of 60 reserve days over your lifetime)

  • Each day after the lifetime reserve days: You pay for everything

Will Medicare Advantage Plans Cover SNF?

Yes, Medicare Advantage plans may cover skilled nursing facility (SNF) care. But each plan can have different rules and costs associated with SNF care. Some plans may require prior authorization and every plan has its own network of providers.

Do Medigap Plans Cover SNF?

Yes. with most Medicare supplement (aka Medigap) Plans you are fully insured for up to 100-days in a SNF. You will have no out-of-pocket cost for your stay.

The Medigap Plans that cover 100% of SNF for 100-days are Medigap Plans C, D, F, G, M and N.

 

 

Where Can I Get Help Understanding Medicare Coverage?

Simply visit MedigapSeminars.org and reach out to us from our site, or call 800-847-9680.

You don’t have to remember all the complex details – we do it for you! Contact us today and let us help you make an informed decision on Medicare.

Source:

https://www.medicare.gov/publications/10153-Medicare-Skilled-Nursing-Facility-Care.pdf

https://www.medicare.gov/coverage/inpatient-rehabilitation-care

https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency. Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views. As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.

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