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Guidelines to Medicare Coverage for Skilled Nursing Facilities


There are some specific Medicare coverage guidelines that pertain to Skilled Nursing Facility services. Skilled nursing services are specific skills that are provided by health care employees like physical therapists, nursing staff, pathologists, and physical therapists. Guidelines include doctor ordered care with certified health care employees. Also, they must treat current conditions or any new condition that occurs during your stay at a Skilled Nursing Facility. Below, we’ll go over what you need to know about Medicare coverage for Skilled Nursing Facilities.

Medicare Coverage Requirements for Skilled Nursing Facilities

There are specific requirements that beneficiaries must meet to qualify for Medicare coverage for Skilled Nursing Facilities. The patient must have been an inpatient of a hospital facility for a minimum of three consecutive days. The patient must go to a Skilled Nursing Facility that has a Medicare certification within thirty days of their hospital discharge.

3 Day Hosptial Stay Rule with Medicare Billing for Coverage in Skilled Nursing Facilities

For a beneficiary to extend healthcare services through SNF’s, the patients must undergo the 3-day rule before admission. The 3-day rule ensures that the beneficiary has a medically necessary stay of 3 consecutive days as an inpatient in a hospital facility. This doesn’t include the day of the patient’s discharge, any outpatient observations, or the time spent in the emergency room.

Exceptions to Medicare 3 Day Hosptial Stay Rule

If the patient’s health conditions are not appropriate for placing into a nursing facility directly after leaving the hospital, the hospital will determine when to begin appropriate care. Another exception to this rule is if the patient requires around the clock nursing services.

Summary of Skilled Nursing Facility Coverage

How Long Does Medicare Pay for Skilled Nursing Care?

Cost of Your Stay in a Skilled Nursing Facility with Medicare

Part A benefits cover 20 days of care in a Skilled Nursing Facility.

After that point, Part A will cover an additional 80 days with the beneficiary’s assistance in paying their coinsurance for every day.

Once the 100-day mark hits, a beneficiary’s Skilled Nursing Facility benefits are “exhausted”.

At this point, the beneficiary will have to assume all costs of care, except for some Part B health services.

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

Benefit periods are how Skilled Nursing Facility coverage is measured. These periods begin on the day that the beneficiary is in the healthcare facility on an inpatient basis. This period ends when the beneficiary is no longer an inpatient and hasn’t been one for 60 consecutive days.

A new benefit period may begin once the prior benefit period ends, and the beneficiary receives another admission to a healthcare facility. One keynote to remember is that a new benefit period is not each calendar year or change to the patient’s diagnosis or health condition.

Unique Skilled Nursing Facility Billing Situations

There are instances where Medicare may require a claim, even when payment isn’t a requirement.

Readmission Within 30 Days

When the beneficiary is discharged from a skilled nursing facility, and then readmitted within 30 days, this is considered readmission. Another instance of readmission is if a beneficiary were to be in the care of a Skilled Nursing Facility and then ended up needing new care within 30 days post the first noncoverage day.

Exhausting Benefits

If a patient exhausts benefits, the monthly bills continue with normal submission; although, the beneficiary must still be in a Medicare facility. Full exhausted benefits mean that the beneficiary doesn’t have any available days on their claim. Partially exhausted benefits mean that the beneficiary had several available benefit days on their claims.

No Payment Billing

No payment billing happens when a patient moves to a non-SNF care level and is in a Medicare facility.

Expediting Review Results for Beneficiaries

Expediting the determination processes can happen when providers initiate discharge from SNF’s because of coverage reasons. Although, beneficiaries can appeal health service terminations through this process.

Noncovered Days

Skilled Nursing Facility requirements must be met to obtain benefits.

Billing Situations Among Other Facilities

If a beneficiary needs a Skilled Nursing Facility and goes but doesn’t have a qualifying stay in a hospital facility, they can move to a Skilled Nursing Facility after they remain for the night. They’ll then go the next night and receive coverage.

FAQs

How long does Medicare pay for skilled nursing care?
Medicare will cover 100% of your costs at a Skilled Nursing Facility for the first 20 days. Between 20-100 days, you’ll have to pay a coinsurance. After 100 days, you’ll have to pay 100% of the costs out of pocket.
Does Medicare pay for hospice in a skilled nursing facility?
Yes, Medicare will cover hospice at a Skilled Nursing Facility as long as they are a Medicare-certified hospice center. However, Medicare will not cover room and board.
What does Medicare consider skilled nursing?
Medicare considers skilled nursing to be physical therapists, nursing staff, pathologists, physical therapists, etc.

Get Help with Medicare Coverage for Skilled Nursing Facilities

If you or a loved one needs help covering out of pocket medical expenses that Medicare doesn’t cover, we can help. Contact our agents today for a free quote on supplemental options available in your area, or you can fill out our supplemental rate form to see your options now.

Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

2 thoughts on “Guidelines to Medicare Coverage for Skilled Nursing Facilities

  1. When is a person eligible for time at a skilled nursing facility ? My mother was sent to one after her broken femur and broken ankle. Her doctor and surgeon want her to spend time past the fully covered 20 day stay. The facility insists she does not need skilled nursing care and will charge the full daily rate instead of the reduced insurance premium rate.

    1. Hi David! Unfortunately, unless your mother has a Medigap plan, she will only have coverage for her skilled nursing facility stay for the first 20 days. Part A only covers 100% of an SNF stay for the first 20 days. For days 21-100, she will have a copay for each additional day.

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