Below is a summary of Medicare Skilled Nursing Facility benefits:
Medicare covers Skilled Nursing services ONLY. Medicare will not, under any circumstances, pay for Intermediate or Custodial nursing facility care.
Medicare Skilled Nursing Facility benefits fall under Medicare Part A.
Skilled Nursing and Rehabilitative services are defined as:
1. Medically necessary. 2. Ordered by a physician. 3. Performed by skilled personnel (i.e,, physical therapist, respiratory therapist, occupational therapist, etc.).
Medicare covers Skilled Nursing Facility care if the following conditions are met:
1. Patient must have spent three overnights as an admitted hospital patient (be wary of “observation” stays in hospital…they do not count toward the three day requirement). 2. Be admitted to a Medicare participating facility. 3. Be admitted within 30 days of hospital discharge. 4. Be admitted for the same condition for which they were hospitalized.
If the above conditions are met then for each Benefit Period:
1. Medicare will pay all charges for the first 20 days. 2. Medicare will pay all charges except for a $161 per day co-pay for the next 80 days (2016). This co-pay may be covered by Medicare supplement or other private insurance. 3. Medicare Skilled Nursing Facility benefits end after 100 days of care per Benefit Period.
What is a “Benefit Period”?
A Benefit Period begins the day (overnight) the beneficiary is admitted to a hospital as a Medicare patient and ends when they been out of the hospital or have not received Medicare Skilled Nursing Facility care for at least 60 days in a row.
In other words, Benefit Periods are separated by 60 days during which the Medicare beneficiary has not received care in a hospital or Skilled Nursing Facility.
After 60 days Medicare Part A benefits “renew” in that the beneficiary will receive all benefits as if benefits had not been previously received (with the exception of “lifetime reserve days” which do not “renew” and do not apply at all to Skilled Nursing Facility benefits). New deductibles and co-pays will also apply. So, too, will the beneficiary have to again meet the hospital stay requirement.
Remember that just because there is a potential 100 day Skilled Nursing Facility benefit per benefit period it does not mean the beneficiary “automatically” will receive the full 100 days. To continue to receive Medicare Skilled Nursing Facility benefits during the covered 100 days the patient:
1. Must be able to participate in prescribed therapies. 2. Must be willing to participate in prescribed therapies. 3. Must be “progressing” in treatment.
If the patient stabilizes or “plateaus” in treatment, they may no longer qualify for skilled services and Medicare benefits will terminate…even if the patient is not capable of caring for themselves or they have not received 100 days of coverage.
This is where Medicaid comes in as the payee of last resort for nursing home care other than skilled or when Medicare skilled benefits are exhausted.
Caveat: The above is applicable to “Original” Medicare. If a beneficiary is covered under a Medicare Advantage Plan (Medicare Part C) actual benefits may vary in terms of co-pays and coverages. Contracts and benefits vary. Consult the contract for details.
I assume you are referring to coverage in a nursing facility. In the case of my parents, it started upon release from the hospital after three consecutive nights spent in the hospital (after admission as an inpatient).
It restarts with a new medical condition. So if you go in for a broken leg and then a month later have a stroke, the clock starts over. There can also be other variables, depending on which company carries your health insurance. Read your policy carefully. For our mom the $100 a day co-pay started on day one.
3 day hospital stay...no exception...and then there has to be an acute condition...chronic doesn't cut it. I was so mad at those doctors that day I could have screamed, but the medicare guidelines are strict...way too strict.
If this is related to skilled rehab days, the patient will need to have NO inpatient hospital days for 61 days to be safe. The requirement is 60 days starting on the day after the original discharge from skilled nursing. If there is a decline in the first 30 days after discharge a patient can return to any SNF rehab with doctors orders and pick up where they left off with any remaining days. If 100 days were used on the last rehab stay, you will need to stay out of hospital for that 6(1) days before you get a new set of 100 days for rehab.
{Q}Did you know that even if you stay in a hospital overnight, you might still be considered an “outpatient?” Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs, and lab tests) and may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay {EQ}
Yes Uncledave is correct. You must be admitted to hospital and stay as an inpatient for 3 days in order th quilify for SNC or rehab. Time spent in er or in observation does not count. Because of the large amounts of people on medicare there is growing pressure on doctors and hospitals not to admit patients. This happened to my mother they would not admit her but held her in observation for 4 days. Since she needed rehab the social worker was able to get her sent to a rehab hospital for 4 days this gave her the medicare required inpatient stay that then allowed her to go to rehab facility near us. But it was a real ordeal for her having to transfer twice.
Some ACO's will partner with skilled nursing facilities (SNF) and allow a waiver so a 3 night qualifying hospital stay is not required, but yes for most people a 3 night stay via admission not observation is required- which also has to be medically reasonable and necessary. In regards to a benefit period in a skilled nursing facility, the information Ralph Robbins provided was very accurate. However your benefit period would only renew after 61 days technically- which unfortunately at anytime in that 61 day period if you happened to return to the hospital and be admitted- you would have to start the count all over again. In regards to pamstegma that is only correct if a 60 (61) day wellness period has occured, if a new diagnosis is made within that time and you returned to a SNF you would "continue on the same track" (ie. admitted to SNF for 6 days fell and broke your hip, went to hospital and returned to SNF would only have 95 days left... because the day of discharge is never billed) . Carolgigi is right on- at anytime within 30 days of being discharged from a SNF you can return and pick up back on your Medicare benefits, but ONLY if the need is related to the original diagnosis (ie. if you were admitted with a UTI finished your antibiotic and went home, but then fell down and felt weak- would probably not correlate). Hope this helped some people out!
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Medicare covers Skilled Nursing services ONLY. Medicare will not, under any circumstances, pay for Intermediate or Custodial nursing facility care.
Medicare Skilled Nursing Facility benefits fall under Medicare Part A.
Skilled Nursing and Rehabilitative services are defined as:
1. Medically necessary.
2. Ordered by a physician.
3. Performed by skilled personnel (i.e,, physical therapist, respiratory therapist, occupational therapist, etc.).
Medicare covers Skilled Nursing Facility care if the following conditions are met:
1. Patient must have spent three overnights as an admitted hospital patient (be wary of “observation” stays in hospital…they do not count toward the three day requirement).
2. Be admitted to a Medicare participating facility.
3. Be admitted within 30 days of hospital discharge.
4. Be admitted for the same condition for which they were hospitalized.
If the above conditions are met then for each Benefit Period:
1. Medicare will pay all charges for the first 20 days.
2. Medicare will pay all charges except for a $161 per day co-pay for the next 80 days (2016). This co-pay may be covered by Medicare supplement or other private insurance.
3. Medicare Skilled Nursing Facility benefits end after 100 days of care per Benefit Period.
What is a “Benefit Period”?
A Benefit Period begins the day (overnight) the beneficiary is admitted to a hospital as a Medicare patient and ends when they been out of the hospital or have not received Medicare Skilled Nursing Facility care for at least 60 days in a row.
In other words, Benefit Periods are separated by 60 days during which the Medicare beneficiary has not received care in a hospital or Skilled Nursing Facility.
After 60 days Medicare Part A benefits “renew” in that the beneficiary will receive all benefits as if benefits had not been previously received (with the exception of “lifetime reserve days” which do not “renew” and do not apply at all to Skilled Nursing Facility benefits). New deductibles and co-pays will also apply. So, too, will the beneficiary have to again meet the hospital stay requirement.
Remember that just because there is a potential 100 day Skilled Nursing Facility benefit per benefit period it does not mean the beneficiary “automatically” will receive the full 100 days.
To continue to receive Medicare Skilled Nursing Facility benefits during the covered 100 days the patient:
1. Must be able to participate in prescribed therapies.
2. Must be willing to participate in prescribed therapies.
3. Must be “progressing” in treatment.
If the patient stabilizes or “plateaus” in treatment, they may no longer qualify for skilled services and Medicare benefits will terminate…even if the patient is not capable of caring for themselves or they have not received 100 days of coverage.
This is where Medicaid comes in as the payee of last resort for nursing home care other than skilled or when Medicare skilled benefits are exhausted.
Caveat: The above is applicable to “Original” Medicare. If a beneficiary is covered under a Medicare Advantage Plan (Medicare Part C) actual benefits may vary in terms of co-pays and coverages. Contracts and benefits vary. Consult the contract for details.
There can also be other variables, depending on which company carries your health insurance. Read your policy carefully. For our mom the $100 a day co-pay started on day one.
be considered an “outpatient?” Your hospital status (whether the hospital
considers you an “inpatient” or “outpatient”) affects how much you pay for
hospital services (like X-rays, drugs, and lab tests) and may also affect whether
Medicare will cover care you get in a skilled nursing facility (SNF) following
your hospital stay {EQ}
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