If your loved one needs care in a skilled nursing facility (SNF), it is crucial to know what Medicare covers and what costs you will be responsible for paying.
Medicare Does Not Pay for Long-Term Care
It is important to understand that Medicare is not intended to cover long-term care services. Medicare generally covers only short-term stays in Medicare-certified skilled nursing facilities. These temporary stays are typically required for seniors who have been hospitalized and are discharged to an inpatient facility as part of their recovery from a serious illness, injury or operation. Pneumonia, stroke and serious falls are a few of the most common medical issues that require this skilled inpatient rehabilitation.
A serious health setback that initially requires temporary care in an SNF often leads to the realization that long-term placement is in fact necessary. Since Medicare coverage is only offered for a limited time, families are often confused and frustrated when they receive notice that their loved ones must either pay for ongoing care privately, apply for Medicaid or be discharged.
The following sections thoroughly explain Medicare’s rules and requirements for coverage of care in SNFs.
How Medicare Measures Skilled Nursing Care Coverage
Medicare measures the use and coverage of skilled nursing care in “benefit periods.” This is a complicated concept that often trips up beneficiaries and their caregivers. Each benefit period begins on the day that a Medicare beneficiary is admitted to the hospital on an inpatient basis. Time spent on an outpatient or observation basis does not trigger the beginning of a benefit period.
Once a benefit period begins, a beneficiary must then have a qualifying three-day inpatient hospital stay in order be eligible for coverage of care in a skilled nursing facility. A benefit period ends when the beneficiary has not received inpatient hospital or SNF care for 60 consecutive days. Once a benefit period ends, a new one can begin the next time the beneficiary enters the hospital. There is no limit to the number of benefit periods a beneficiary can have.
Patient Criteria for Medicare Coverage of SNF Stays
Medicare will cover inpatient skilled care only if all the following criteria are met:
- The beneficiary has Medicare Part A (hospital insurance) and days left in their benefit period available to use.
- The beneficiary has a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more, starting with the day the hospital admits them as an inpatient, but not including any outpatient or observation days or the day they leave the hospital.
- Following a qualifying hospital stay, a beneficiary must enter the skilled nursing facility within a short period of time (generally 30 days) of being discharged.
- The beneficiary’s doctor must order skilled nursing care, which requires the skills and oversight of professional personnel, such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists.
- The beneficiary requires skilled care on a daily basis and the specific services needed must be ones that can only be provided in an SNF on an inpatient basis. (If care in an SNF is needed for skilled rehabilitation services only, it is still considered daily care even if the therapy services are only offered 5 or 6 days a week.)
- The beneficiary must need skilled services for the medical condition that was treated during their qualifying three-day hospital stay or a related condition. (For example, if you are receiving covered care because you broke your hip and then have a stroke, Medicare may cover rehabilitation services for the stroke, even if you no longer need rehabilitation for your hip.)
- A beneficiary’s prescribed skilled services must be reasonable and necessary for the diagnosis or treatment of their eligible condition.
How Long will Medicare Pay for a Stay in a Skilled Nursing Facility?
If a beneficiary meets all the requirements above, the amount Medicare covers depends on how long they need to stay in the SNF because coverage decreases over time. Keep in mind that seniors with Medigap policies or Medicare Advantage Plans may have additional coverage for SNF stays. Here is a breakdown of how Medicare covers SNF stays:
- Days 1 through 20: Medicare pays the full cost for each benefit period.
- Days 21 through 100: Medicare pays all but a daily coinsurance. In 2018, the coinsurance is $167.50 per day.
- After 100 days: Medicare provides no coverage after 100 days. Beneficiaries must pay for any additional days out of pocket, apply for Medicaid coverage, explore other payment options or risk discharge from the facility.
Sometimes beneficiaries take “breaks” from this care that can change their eligibility for coverage. For example, if a beneficiary leaves the SNF for less than 30 days and then needs to return for the same medical condition (or a related one), they will not need another qualifying three-day hospital stay to be eligible for additional SNF coverage left in their benefit period.
If the break lasts for 60 consecutive days, then this triggers the end of a benefit period and the beneficiary’s SNF benefits are renewed only after they meet the above requirements again.
Debunking Medicare’s “Improvement Standard”
For many years, nursing homes told their patients that Medicare would cease paying for skilled nursing care if the patient’s health stopped improving or had “plateaued” within their covered benefit period. However, Jimmo v. Sebelius, a 2013 federal court settlement, prompted the government to make an admission about this policy:
“Medicare has never supported the imposition of this ‘Improvement Standard’ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition.”
In the current Manual for Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage, the government now admits that Medicare “coverage depends not on the beneficiary’s restoration potential” but simply “on whether skilled care is required.”
This manual was published in 2014, but some SNFs haven’t adapted to help chronic patients get access to the coverage they are eligible for. Furthermore, many business offices rely on software programs to manage their billing, and some of those programs haven’t caught up.
Ensuring Medicare Will Pay
There is so much room for interpretation (and reinterpretation) surrounding the rules for Medicare coverage that it’s easy for families to become confused on how to pay for care in SNFs. The bottom line is that vigilance and advocacy by family members will be necessary to ensure their loved ones receive the skilled care they need and the coverage they are entitled to.
You must make sure that the hospital staff and SNF staff give detailed orders and reasons for the skilled services that are needed to promote your loved one’s health and safety. Carefully tracking the days within their benefit period can be confusing, but this is necessary to avoid any surprises regarding non-coverage.
Hiring a geriatric care manager (GCM) to track the nursing home chart and timeline and accompany you to care plan meetings may be a wise investment. These professionals have a great deal of experience with seniors, elder care providers and Medicare. Even if your loved one has run out of Medicare coverage, a GCM can help you find and access other sources of financial assistance and alternative types of care.
Other Ways to Pay for Skilled Nursing Care
There are other sources of help available for covering skilled care and other healthcare costs. If a senior’s income and resources are limited, they may be eligible through their state’s Medicaid program for assistance with paying for skilled and/or custodial care, medications and other medical expenses. If they qualify for both Medicare and Medicaid, most health care costs are typically covered.