Many doctors refer patients to skilled nursing facilities to recover from a significant illness or surgery. These facilities cost less than hospitalization and are a valuable alternative. Medicare Part A will pay for some of the expenses associated with a stay at a skilled nursing facility, but there are strict limitations to the amount of coverage.
What Is a Skilled Nursing Facility?
A patient receives skilled nursing care in a nursing facility or an extended care wing of a hospital. Skilled nursing facilities provide high levels of nursing and medical care, along with intensive rehabilitation and 24-hour monitoring. It is meant to follow an acute hospital stay due to surgery, injury, or severe illness. A stay in a nursing facility typically lasts for only a matter of days or weeks.
What Are the Requirements for Medicare Coverage?
It used to be that Medicare required that there be an expectancy for your condition to improve. Now, coverage is available for skilled nursing care if it’s necessary to slow deterioration or maintain your health. However, there are two conditions you must meet for Medicare to cover any portion of the costs for care:
Recent stay at a hospital
You must have been hospitalized for three consecutive days — not including your discharge date. You need to have been admitted into the hospital and not merely kept there for observation. You must begin your stay at the facility within 30 days following your hospital discharge. If for whatever reason your Medicare coverage starts at the nursing facility and you leave soon after but are readmitted within 30 days, Medicare will also pay for the second period as well.
Doctor certifies the need for skilled nursing care
Medicare needs your doctor to sign off on there being a need for you to stay in a skilled nursing facility for daily care. The care can include treatment requiring a trained professional for administering medicines, giving injections, monitoring vital signs, or changing dressings, or rehabilitative services, such as speech, occupational, or physical therapy. Any daily care required needs to have a direct relation to the condition for which you were hospitalized.
Services Medicare Covers
The services and care received at a skilled nursing facility covered are identical to those at a hospital. These include:
- Rehabilitation services, such as speech pathology, occupational and physical therapy for your stay at the facility.
- A room that is semiprivate with two or more beds, or a private room if it is deemed medically necessary.
- Drugs, treatments, medical supplies, and other appliances, such as a wheelchair, splints, casts, and so forth.
- Meals, including special diets if medically required.
- Special care units, like cardiac intensive care.
- Regular nursing services.
For the first 20 days, Medicare insurance will cover 100 percent of the expenses for your stay but any days afterward will require a copay.
Is There Anything Medicare Won’t Cover? The coverage for skilled nursing care does not extend to:
- A non-medically necessary private room.
- Telephone, radio, television, or other personal conveniences.
- Nurses for private duty.
How Much of the Cost Does Medicare Pay?
For each episode of illness, Medicare insurance will cover a total of 100 days for skilled nursing inpatient care as long as your doctor continues to prescribe nursing therapy or supervision. As mentioned earlier, Medicare will cover all the costs for the first 20 out of 100 days, which includes essential services only. For the remaining 80 days, you are responsible for the daily copay, and Medicare will take care of the rest. After the 100-day benefit period ends, Medicare Part A will stop its coverage, and you’ll have to pay on your own. If later on, you start another spell of illness, a new benefit period of 100 days will begin for coverage. Lifetime reserve days are only available for hospital coverage and do not apply to a stay at a skilled nursing facility.
If you are enrolled in Original Medicare and have purchased a Medigap policy to supplement your insurance, your Medigap benefits may help cover the costs of copayments, coinsurance, and deductibles. If you receive your Medicare benefits through a Medicare Advantage plan, you will have the same Part A and Part B benefits as Original Medicare, but many MA plans offer additional coverage at little to no extra cost. Check with your plan to find out your exact cost of your stay in a skilled nursing facility.