Medicare Coverage & Skilled Nursing Care

Elderly woman discussing medicare with a nurse in a skilled nursing facility.

While Medicare will provide coverage for skilled nursing facility services, there are some specific coverage guidelines that providers and beneficiaries must follow. Skilled nursing services are particular skilled services provided by health care workers such as physical therapists, nursing staff, and pathologists. The guidelines surrounding such coverage also includes doctor ordered care with certified health care employees. Additionally, the care must treat current conditions or any new conditions that you become aware of during your stay at the skilled nursing facility. This article will go into further detail about what you need to know if you’re on Medicare and need the services of a skilled nursing facility.

Medicare Coverage Requirements for Skilled Nursing Facilities

There are certain specific requirements that Medicare beneficiaries must meet in order to qualify for Medicare coverage in a skilled nursing facility. The patient must have been an inpatient of a hospital for a minimum of three consecutive days. Further, the patient must also go to a Medicare-certified skilled nursing facility within thirty days of being discharged from the hospital.

Skilled nursing care is wide-ranging, but in 2019 some of the most common reasons people needed skilled nursing care were:

  • septicemia
  • joint replacement
  • heart failure
  • shock
  • hip and femur procedures, aside from joint replacement
  • kidney and urinary tract infections
  • COPD
  • renal failure
  • pneumonia

3 Day Hospital Stay Rule 

Again, for a patient to receive extended healthcare services via a skilled nursing facility, the patient must have been in inpatient care at a hospital for at least three consecutive days before admission. This three-day rule is in place to ensure that the patient has a medically necessary condition that falls under Medicare coverage. However, you should note that the day of the patients’ discharge from the hospital, any outpatient observations, or the time spent in the emergency room do not count toward your three days. 

Exceptions to Medicare 3 Day Hospital Stay Rule

There are a few exceptions to the three-day rule, though. For example, suppose the patient’s health conditions are such that they do not require placement into a skilled nursing facility directly after being discharged from the hospital. In that case, the hospital employees will determine the next steps for appropriate care. Another exception may be if the Medicare beneficiary requires around the clock nursing services.

How Much Will Medicare Cover If I Need Skilled Nursing Care?

Medicare Part A is what will provide your coverage during your stay in a skilled nursing facility. Your coverage under Part A will be as follows:

  • For your first 20 days of care, Medicare will cover the entire cost. You will pay nothing at all. 
  • For the next 80 days (days 21-100 of care), Medicare will cover a majority of the costs, but you will be responsible for your daily co-payment. In 2020, the daily co-payment was $176 a day. 
  • From day 100 and on, Medicare will not cover any skilled nursing facility care. Once you have reached the 100-day limit, you will be responsible for the entirety of your care costs moving forward. 

Will Medicare Part B Cover My Stay at a Skilled Nursing Facility?

Medicare Part B may cover some treatments and medicines, but generally, this benefit will not cover you at a skilled nursing facility. This is because Part B is generally for outpatient care, not inpatient.

Senior man working out in a skilled nursing facility.
A benefit period is how skilled nursing facility coverage gets measured by Medicare.

What is the Benefit Period for Skilled Nursing Facility with Medicare?

A benefit period is how skilled nursing facility coverage gets measured by Medicare. The period begins on the day the patient begins care at the health care facility on an inpatient basis. The period ends when the patient is no longer receiving inpatient care and hasn’t required such care for 60 consecutive days.

A new benefit period can open back up when the old ends and the patient has been readmitted into inpatient care at a skilled nursing facility. It is important to keep in mind that a new benefit period does not necessarily start every calendar year, nor does it restart if the patient receives a new diagnosis or health condition.

How Does Billing Work for Skilled Nursing Facility Care?

Depending on your situation, Medicare may require a claim, even if payment is not a requirement.

Readmission to a Facility within 30 Days

In circumstances where the patient has been discharged from a skilled nursing facility but then is readmitted within 30 days, the patient can do so without beginning a new benefit period.

Exhausting Benefits

If you are on Medicare and have exhausted your benefits, your monthly bills will continue with normal submission, although you must still be in a Medicare facility. If you have fully exhausted all of your benefits, you will not have any available days left on your claim, and you will be responsible for the full cost of coverage.

No Payment Billing

No payment billing is when a patient is moved to a skilled nursing facility care level in a Medicare-certified facility.

Billing Situations from Other Facilities

If you’re in need of a skilled nursing facility, but you do not first have a qualifying stay in a hospital, you can still be moved to a skilled nursing facility and stay the night. The following day you should begin to receive coverage.

Does Medicare pay for hospice in a skilled nursing facility?

Yes. Medicare will cover hospice care at a skilled nursing facility so long as the care center is Medicare-certified. However, Medicare will not cover your room and board charges.

Medicare Coverage & Skilled Nursing Facilities

As with everything Medicare, there are a number of rules and regulations guiding your care coverage at a skilled nursing facility. There are countless reasons why you may need to check into a skilled nursing facility, yet nonetheless, in order to receive coverage, certain steps have to be followed.

If you think that you may be facing out-of-pocket expenses that normal Medicare coverage won’t cover, you can call our office or send us an email, and one of our licensed experts will walk you through supplemental care options.

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