- Medicare coverage for skilled nursing facilities is limited.
- Skilled nursing facility coverage requires an initial hospital stay.
- Medical services are covered for an initial 100-day period after a hospital stay.
- Copayments apply beyond the initial coverage period.
If you think Medicare will pay for skilled nursing care, you’re not wrong. However, coverage limits can be confusing, and there are certain requirements you have to meet before your stay.
In a nutshell, Medicare will pay for short-term skilled nursing facility stays for specific situations. If you need ongoing or long-term care in a skilled nursing facility, you will have to pay out of pocket or use other programs to fund these services.
The short answer is yes. Medicare is a federal healthcare program for people age 65 and over, and those with qualifying medical conditions. Medicare coverage is split into a few different programs, each offering different types of coverage at various costs.
Medicare Part A
Medicare Part A provides inpatient hospital coverage. Part A and Part B together is sometimes called “original Medicare.” The Medicare Part A monthly premium is usually free if you paid into the Medicare system through taxes during a portion of your working years.
You enroll in Medicare Part A when you turn 65 or if you have certain medical conditions. This is the portion of Medicare that will cover your skilled nursing facility stay, rehabilitation center stay, hospice care, and certain home health care services.
Medicare Part B
Medicare Part B will cost you a monthly premium that based on your income level. Most people will pay $144.60 per month in 2020. Part B covers most outpatient medical care.
Medicare Part C
Medicare Part C, or Medicare Advantage, plans are sold by private insurance companies. These plans combine all the elements of original Medicare and sometimes extra coverage for prescription drugs, vision, dental, and more. There are many different Medicare Advantage plans available, so you can choose one based on your needs and financial situation.
Medicare Part D and Medigap
There is also Medicare Part D, which provides prescription drug coverage. Private supplemental plans, called Medigap, can also offer extra coverage for services not paid for under the other Medicare programs.
Medicare Part A covers the cost of a skilled nursing facility for conditions that begin with a hospital stay and require ongoing care after discharge. While this seems simple, there are a few specifics conditions that apply, including:
- Your illness or injury must require a hospital stay. Some examples of these events are a fall, stroke, heart attack, pneumonia, worsening heart failure or chronic obstructive pulmonary disease (COPD), or surgery.
- There is a required length of stay. The initial hospital stay must last a minimum of 3 days.
- While in the hospital, you must be considered an inpatient. Being in the hospital under observation is not considered a qualifying hospital stay. Time spent in the emergency department, under observation, and the day of discharge cannot be counted toward Medicare’s 3-day rule.
- When discharged, your doctor must order ongoing care. This means that you require 24-hour care at a skilled nursing facility for the condition for which you were hospitalized.
- You are covered for any conditions you develop while at a skilled nursing facility. An example of this could be if you get an infection while receiving rehab services after joint replacement surgery.
When you are discharged from the hospital due to an injury or new illness, your doctor will determine if you need additional care. This decision is based on your ability to take care of yourself at home, if you have help available at home, and what kind of care is needed for your medical condition.
If you need special therapies or treatments to recover, or your condition requires a professional or trained help, the doctor may say you need skilled nursing care.
In 2019, the most common conditions that required skilled nursing care were:
- joint replacement
- heart failure
- hip and femur procedures, aside from joint replacement
- kidney and urinary tract infections
- renal failure
Medicare’s coverage for skilled nursing facilities is broken down into benefit periods. A benefit period begins the day you are admitted as an inpatient to the hospital or skilled nursing facility.
Different amounts are paid throughout the benefit period. The benefit period ends when 60 days in a row have passed without a need for hospital or skilled nursing care. If you go back to the hospital after that 60-day window, a new benefit period begins.
Here are the costs that apply throughout the benefit period:
- Days 1 through 20: Medicare covers the entire cost of your care for the first 20 days. You will pay nothing.
- Days 21 through 100: Medicare covers the majority of the cost, but you will owe a daily copayment. In 2020, this copayment is $176 per day.
- Day 100 and on: Medicare does not cover skilled nursing facility costs beyond day 100. At this point, you are responsible for the entire cost of care.
While you are in a skilled nursing facility, there are some exceptions on what is covered, even within the first 20-day window.
Items and services covered by Medicare:
- a semi-private room, unless a private room is medically necessary
- transportation for medical services not available at the skilled nursing facility
- skilled nursing care
- medical supplies
- meals and dietary counseling
- physical therapy, if needed
- occupational therapy, if needed
- speech therapy, if needed
- social services
Items and services NOT covered by Medicare:
- Additional telephone or television charges not covered by the facility
- Private duty nursing services
- Personal items such as razors, toothpaste, and other personal hygiene items
There are some additional rules about Medicare coverage that you should know, including:
- Your doctor can request additional services on your behalf that aren’t typically covered by Medicare.
- If you leave the skilled nursing facility and need to return within 30 days, you can do so without starting a new benefit period.
- Medicare coverage will not pay for long-term care. Long-term care can include custodial care, which is when you need help with your daily activities but don’t need a medical professional, and assisted living, which is a residential setting that sometimes offers medical care as well.
Skilled care is nursing or therapy services that must be performed by or supervised by a professional. This may include wound care, physical therapy, giving IV medication, and more.
Skilled nursing facilities can be located within hospital units, but these are the minority. Most skilled nursing facilities are stand-alone, private, for-profit businesses. They usually provide many types of services, such as short-term medical care, rehabilitation, and long-term care.
Medicare offers an online tool to help you find approved skilled nursing facilities. Case managers and social workers can also help you with coverage for your hospital or skilled nursing facility stay.
Medicare will also cover rehabilitation services. These services are similar to those for skilled nursing, but offer intensive rehabilitation, ongoing medical care, and coordinated care from doctors and therapists.
The same types of items and services are covered by Medicare in a rehabilitation facility (a shared room, meals, medications, therapies) as with a skilled nursing facility. The same exclusions (television and phone services, and personal hygiene items) apply as well.
You may require inpatient rehabilitation for a brain injury that requires both neurological and physical therapies. It could also be another type of traumatic injury that affects multiple systems within the body.
The amount of coverage for inpatient rehabilitation is a little different than skilled nursing. Medicare Part A costs for each benefit period are:
- Days 1 through 60: A deductible applies for the first 60 days of care, which is is $1,364 for rehabilitation services.
- Days 61 through 90: You will pay a daily coinsurance of $341.
- Days 91 and on: After day 90 for each benefit period, there is a daily coinsurance of $682 per “lifetime reserve day” (these are 60 additional days of coverage that can be used only once during your lifetime).
- After lifetime reserve days: You must pay all costs of care after your lifetime reserve days have been used.
In addition to Medicare Advantage and Medigap plans, there are a number of public and private programs to help pay for skilled nursing costs. A few examples include:
- PACE (Program of All-inclusive Care for the Elderly), a Medicare/Medicaid program that helps people meet healthcare needs within their community.
- Medicare savings programs, which offer help from your state to pay your Medicare premiums.
- Medicare’s Extra Help program, which can be used to offset medication costs.
- Medicaid, which may be used to help fund long-term care needs, if you’re eligible.
A few last tips
- If you think you may need skilled nursing care after a hospital stay, talk to your doctor early.
- Make sure you are listed as an inpatient, not an observation patient, during your admission.
- Ask the doctor to document any information that would prove skilled nursing care is necessary for your illness or condition.
- Consider hiring a
geriatric care managerto help plan your care needs and coordinate coverage.
- If you are able to go home, and you have someone to help you there, then Medicare will cover certain at-home therapies.
- Review the different Medicare program options, and consider what kind of coverage you may need in the future before choosing a plan.
- Check to see if you qualify for Medicaid assistance in your state or other public and private assistance programs.
- Medicare will pay for short-term care in a skilled nursing or rehabilitation facilities.
- The amount covered depends on your condition, how long you need care, and what supplemental insurance products you have.
- Medicare will not pay for long-term care.
- Consider your future healthcare needs when you sign up for Medicare and weigh your program options.