Skilled Nursing Care and Medicare
This article was updated on: 09/15/2018
Medicare defines a skilled nursing facility as “a nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.”
When could I need skilled nursing care?
You may need skilled nursing care if you have an illness or injury that requires treatment or monitoring. Skilled nursing facilities provide 24-hour care for people who need rehabilitation services or who suffer from serious health issues that are too complicated to be tended at home. Some skilled nursing facilities might have laboratory, radiology and pharmacy services, social and educational programs, and limited transportation to needed health services that are not available at the facility.
At a skilled nursing facility, you normally get health services according the care plan that your doctor created based on your specific needs. Examples of these health-care services could be:
- A nurse treats a post-operative wound or gives intravenous medications.
- A physical therapist works with a resident to improve strength and balance.
- A speech therapist helps a resident regain speech after a stroke.
- An occupational therapist helps a resident become independent again and handle daily living activities such as eating, dressing and bathing.
Medicare may pay a portion of skilled nursing care costs when this care is delivered in a Medicare-approved skilled nursing facility – usually for a short-term stay.
When would I be eligible for Medicare coverage of skilled nursing facility care?
Generally Medicare will help pay for skilled nursing facility (SNF) care if all of these are true:
- You were a hospital inpatient for at least three days in a row (not counting the day you leave), and you entered a Medicare-certified skilled nursing facility within 30 days of leaving the hospital.
- You’re enrolled in Medicare Part A (hospital insurance).
- Your doctor orders skilled nursing care seven days a week or certain skilled therapy services at least five days a week.
- You need care that can only be provided in a skilled nursing facility, and the services are considered reasonable and necessary.
- Your SNF care is related to a condition you were treated for in the hospital, or is a new condition that started during that treatment.
- You haven’t used up all the days in your Medicare benefit period. A benefit period starts the day you’re admitted to a hospital as an inpatient. It ends when you haven’t been an inpatient in a hospital or skilled nursing facility for 60 days in a row.
If you meet these requirements, Medicare may cover skilled nursing facility care to help you get better or help prevent your condition from getting worse.
What skilled nursing facility services does Medicare cover?
Typically Medicare will pay for the following items and services delivered by trained health professionals:
- Semi-private room
- Care by registered nurses
- Therapy care (including physical, speech and occupational therapy)
- Medical social services
- Nutrition counseling
- Prescription medications
- Certain medical equipment and supplies
- Ambulance transportation (when other transportation would be dangerous to your health) if you need care that’s not available at the skilled nursing facility
Generally Medicare will pay 100% of the Medicare-approved cost for the first 20 days and part of the cost for another 80 days of medically necessary care in a Medicare-certified skilled nursing facility each benefit period.
- You typically need to pay coinsurance for days 21-100.
- If your stay in a skilled nursing facility longer than 100 days in a benefit period, Medicare generally doesn’t cover these costs.
How can I get help paying skilled nursing facility costs?
You might want to consider a Medicare Supplement plan for help paying some of your skilled nursing facility out-of-pocket costs. Medicare Supplement (Medigap) plans help pay for some of your out-of-pocket costs under Medicare Part A and Part B, including certain cost-sharing expenses. In most states, plan benefits are standardized across 10 plan types (labeled letters A through N), and each plan includes different benefits and level of coverage. Several of these standardized plans may cover at least a portion of skilled nursing facility copayments.
If you have long-term care insurance, it may help you pay for this care or, if your income is low, Medicaid might pay for it. You can call your state Medicaid office for more information regarding eligibility and coverage; also, you may contact your State Health Insurance Assistance Program (SHIP) for additional information on any state programs that may help you.
How can I find a Medicare-certified skilled nursing facility?
You can call Medicare to find out about Medicare-certified skilled nursing facilities in your area. Call Medicare at 1-800-MEDICARE (1-800-633-4227, TTY users: 1-877-486-2048) and speak with a counselor; they answer the phones 24 hours a day, seven days a week, except on certain federal holidays. Or you can visit Medicare’s web site at Medicare.gov to search and compare skilled nursing facilities. At this web site you may also want to read the guide to choosing a nursing home and/or the checklist of questions to ask when you are visiting skilled nursing facilities.
Can I help you further with your questions about skilled nursing facilities or your options when it comes to Medicare coverage? You can use the links below to schedule a phone appointment or have me email personalized information to you. If you would like to compare plans on your own, you can use the Compare Plans or Find Plans buttons on this page.