Medicare Skilled Nursing Facility Coverage
Medicare Part A covers skilled nursing facility care for up to 100 days for each illness during your benefit period. Medicare pays if you have received inpatient hospital care for at least three days and if you are admitted into a skilled nursing facility within 30 days of leaving the hospital.
Skilled Nursing Facility Coverage Under Medicare
Skilled nursing facility (SNF) care is highly specialized therapy or nursing care. It can only be performed safely and effectively by or under the supervision of professionals, according to the U.S. Centers for Medicare and Medicaid Services.
You may need SNF care if you need professional or highly skilled technical personnel to treat, manage and observe your condition while evaluating your care.
- Dietary counselling
- Medical social services
- Medical supplies and equipment used in the facility
- Occupational therapy
- Physical therapy
- Semi-private room
- Skilled nursing care
- Speech-language pathology services
- Swing bed services (the ability of a facility to “swing” beds between acute hospital care or SNF care as needed)
- Transportation by ambulance
Other situations may affect your coverage and costs. These services include observation that helps health care providers determine if you need to be admitted to the hospital or can be discharged.
Also be aware that if you have to be readmitted to the hospital during your skilled nursing facility stay, there is no guarantee that you’ll be able to return to the same SNF when you are discharged from the hospital.
Who Qualifies for Skilled Nursing Facility Care?
Medicare Part A covers skilled nursing facility care in certain situations. If you meet all the criteria for coverage, you’ll be covered for up to 100 days in an SNF.
To qualify for Medicare coverage of your SNF stay, you must first be hospitalized for three days before being transferred to a skilled nursing facility. You must also need the care due to one of two medical conditions.
- A hospital-related condition for which you were treated during your qualifying three-day inpatient hospital stay. This can include a condition that developed during the stay, not just the reason you were first hospitalized.
- A condition that started during your SNF care that may be unrelated to the reason you were there in the first place.
In addition, you have to meet a list of other requirements to qualify for Medicare coverage.
- You have Medicare Part A.
- You have days left in your benefit period you can use.
- Your doctor has decided you need daily skilled care.
- Any skilled nursing care you receive must be given by or under the supervision of skilled nursing or therapy staff.
- You receive skilled services in a Medicare-certified skilled nursing facility.
Medicare will only cover skilled nursing facility care for a limited time. Any time spent in SNF beyond 100 days for the same condition within the same benefit period is considered long-term care and is not covered by Medicare.
Assessments in Skilled Nursing Facilities
If you have to go into a skilled nursing facility, professionals from different specialties based on your health needs will plan your care.
The team will conduct daily assessments, gathering information they will use to work with you and your doctor to determine what services you need.
- An inventory of the medicines you are taking.
- How well you can handle routine, daily activities such as bathing, eating or getting in and out of bed or a chair.
- Your current physical and mental condition.
- Your decision-making ability.
- Your medical history.
- Your physical limitations including hearing, vision, stroke-related paralysis or issues with your balance.
- Your ability to speak.
Costs Under Original Medicare
Medicare will cover all costs of your first 20 days in a skilled nursing facility. After that, you will be responsible for part or all of your costs.
|Time in SNF Care||Your Cost|
|Days 1 to 20||$0 for each benefit period|
|Days 21 to 100||$176.00 coinsurance per day of each benefit period (2020 cost, but this can change year-to-year)|
|Day 101 and beyond||All costs|
You are responsible for coinsurance costs for days 21 through 100 of skilled nursing facility care. Medicare adjusts the amount you are responsible for each year. You are also responsible for all costs beyond 100 days during a benefit period.
Paying for Skilled Nursing Facility Care
There are several programs that may help you cover your out-of-pocket costs for skilled nursing care. You can call your state Medicaid office for more information about these programs and whether they are right for you.
State Medicare Savings Programs can help pay premiums, deductibles, copayments and prescription drug costs if you meet certain conditions. You must have limited resources in checking or savings accounts, stocks and bonds to qualify.
Medicaid is a joint state and federal program that helps with medical costs for some people who have limited income and financial resources. It may offer benefits for services not covered by Medicare.
In some cases, PACE, or Program of All-inclusive Care for the Elderly, may be an alternative if the services you require can be performed in the home, community or a local PACE center.
PACE is a joint Medicare and Medicaid program that helps people meet health care needs in their community instead of going into a nursing home or other care facility. You may be required to use a PACE-preferred doctor when you enroll.
11 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2019, July). Medicare Coverage of Skilled Nursing Facility Care. Retrieved from https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf
- Center for Medicare Advocacy. (2016). Medicare Skilled Nursing Facility Coverage. Retrieved from https://www.medicareadvocacy.org/wp-content/uploads/2016/06/Medicare-Skilled-Nursing-Facility-Coverage.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Skilled Nursing Facility (SNF) Care. Retrieved from https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
- U.S. Centers for Medicare & Medicaid Services. (n.d.). What’s an Assessment in Skilled Nursing Facilities? Retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-an-assessment-in-skilled-nursing-facilities
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Skilled Nursing Facility (SNF) Checklist. Retrieved from https://www.medicare.gov/sites/default/files/2018-07/skilled-nursing-facility-checklist_0.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Get Help Paying Costs. Retrieved from https://www.medicare.gov/your-medicare-costs/get-help-paying-costs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Part Coverage – Skilled Nursing Facility Care. Retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/medicare-part-a-coverage-skilled-nursing-facility-care
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Swing Bed Services. Retrieved from https://www.medicare.gov/coverage/swing-bed-services
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicaid. Retrieved from https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicaid
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Savings Programs. Retrieved from https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). PACE. Retrieved from https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/pace