Skilled Nursing Care

Skilled Nursing Care

Medicare covers skilled nursing facility (SNF) care.

What Skilled Nursing Care is

Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. It is health care given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and evaluate your care. Skilled nursing care is commonly referred to as “rehab”.

Medicare-covered services include, but aren’t limited to:

• Semi-private room (a room you share with other patients)
• Meals
• Skilled nursing care
• Physical therapy (if needed to meet your health goal)
• Occupational therapy (if needed to meet your health goal)
• Speech-language pathology services (if they’re needed to meet your health goal)
• Medical social services
• Medications
• Medical supplies and equipment used in the facility
• Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
• Dietary counseling
• Swing bed services

Skilled nursing facility (SNF) care

Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a SNF in certain conditions for a limited time (on a short-term basis) if all of these conditions are met:

• You have Part A and have days left in your benefit period to use.
• You have a qualifying hospital stay.
• Your doctor has decided that you need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff.
• You get these skilled services in an SNF that’s certified by Medicare.
• You need these skilled services for a medical condition that’s either:
  • A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital.
  • A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you’re getting SNF care).

Your costs in Original Medicare

You will pay:

• Days 1–20: $0 for each benefit period.
• Days 21–100: $200.00 coinsurance per day of each benefit period for 2023.
• Days 101 and beyond: all costs.

Skilled nursing facility (SNF) situations

There are some situations that may impact your coverage and costs.

Observation services

Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.

Readmission to a hospital

If you’re in an SNF, there may be situations where you need to be readmitted to the hospital. If this happens, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.

Meeting the 3-day inpatient hospital stay requirement

Here are some examples of common hospital situations that show if you’ve met the 3-day inpatient hospital stay requirement:

Situation 1: You came to the Emergency Department (ED) and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day.

Is my SNF stay covered? Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.

Situation 2: You came to the ED and spent one-day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days.

Is my SNF stay covered? No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Refusing care

If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (like if you get the flu), you may be able to continue to get Medicare coverage temporarily.

Stopping care or leaving

If you stop getting skilled care in the SNF or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

Note

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Source: Medicare.gov