Does Medicare cover the costs of skilled nursing facilities?

Medicare provides coverage for care required at a skilled nursing facility (SNF) up to a 100-day limit. The amount a person has to contribute to their care payments depends on the length of their stay.

If a person is ready to leave the hospital but still requires certain types of specialized care, they may be transferred to a skilled nursing facility.

A skilled nursing facility is a healthcare facility that provides in-person, 24-hour medical care.

Medicare Part A may cover skilled nursing facility care for a limited time, and this article will look at the coverage options in more detail.

What is a skilled nursing facility?

A skilled nursing facility (SNF) is a healthcare facility that provides on-site, 24-hour medical care. The facilities offer post-hospital nursing care, including:

• administering and monitoring prescribed medication

• tube feedings

• wound care

• physical therapy and exercise

• bathing and hygiene

Skilled nursing facilities may be affiliated with nursing homes or hospitals.

Glossary of Medicare terms

We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:

• Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.

• Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.

• Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.

• Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

Eligibility

Medicare Part A may cover skilled nursing facility care if a person has days left in their benefit period to use.

Rules

There are certain rules that must be followed when considering coverage options for an SNF. For Medicare to cover costs, the following rules apply:

• A person must have been formally admitted to a hospital as an inpatient for at least three days in a row before being transferred to the SNF.

• An individual must enter a Medicare-certified SNF within 30 days of leaving the hospital.

• Treatment at the SNF should be for the same health condition that a person received treatment for at the hospital, and care should be required seven days a week.

• If therapy services are required, treatment should be needed a minimum of five days per week.

An individual may initially have to go to the hospital for one health condition but develop another while admitted, which also requires hospital treatment.

If a person meets the three-day qualifying period, the new condition will be eligible for coverage at an SNF, should it be required.

Medicare also usually covers a health condition, such as a new infection that begins while a person is receiving care in a skilled nursing facility.

Coverage

Medicare-covered services during a stay at an SNF include, but are not limited to:

• some ambulance transportation services

• dietary counseling

• meals

• medical social services

• medical supplies and equipment used in the facility

• occupational therapy (if required)

• physical therapy (if required)

• prescription drugs

• semi-private room (a room a person shares with someone else)

• skilled nursing care

• speech-language pathology services (if required)

• swing bed services

A person can talk with their doctor or hospital discharge planner to get help finding a Medicare-certified SNF that meets their needs.

Medicare 100-day limit

Medicare pays differently, depending on how long a person is in an SNF. After day 20, a person must pay a copayment, which increases with the stay’s length.

The table below shows how copayments change. The copayment applies to each benefit period.

It may be of use to a person or caregiver to keep track of the number of days spent in a skilled nursing facility, to avoid unexpected costs.

Benefit period

A person’s benefit period is 60 days, and it applies to hospital and SNF stays. Once a person has been home from the hospital or SNF for 60 days in a row, a new admission would result in a new benefit period.

This means that an individual may be eligible for another 100 days of Medicare-approved SNF care after a qualifying inpatient hospital stay.

After 100 days

After 100 days, Medicare may continue to cover medically necessary skilled therapy services while a person is in the SNF, but they may have to pay the cost of room and board out of pocket.

Individuals can check with Medicare to see if they qualify for at-home therapy through the Medicare home health benefit.

A doctor may also advise that a person is now able to safely receive therapy as an outpatient, at which point different coverage options may apply.

Extra financial help

If a person does not meet the requirements for the skilled nursing facility benefit, or the person has reached the 100-day limit for SNF care, Medicaid may be able to offer nursing facility services to those eligible.

If a person has a Medicare Advantage plan, they can contact their insurer to discover which SNFs are in-network, as participating facilities are usually more cost-effective.

Summary

A skilled nursing facility (SNF) is a healthcare facility that provides 24-hour medical care. SNFs provide post-hospital nursing care.

Medicare-approved SNF services are covered by Medicare Part A, provided a person meets the eligibility criteria.

If a person does not meet the requirements for the skilled nursing facility benefit or the person has reached the 100-day limit for SNF care, Medicaid may be able to help pay for the care.

View the original article on Medical News Today