How many days will medicare pay for skilled nursing facility

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• January 7th, 2022

Many people believe that Medicare covers nursing home stays. In fact Medicare's coverage of nursing home care is quite limited. Medicare covers up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered. The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.

In order for a nursing home stay to be covered by Medicare, you have to meet the following requirements:

• You must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; "observation status" does not count) that itself lasted for at least three days (not counting the day of discharge).
• The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
• You must receive a "skilled" level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered "skilled," nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse or licensed practical nurse. Moreover, such care must be delivered on a daily basis. (Few nursing home residents receive this level of care.)
• Medicare only covers "acute" care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing. Many nursing homes assume in error that if a patient has stopped making progress towards recovery, then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain his or her status (or to slow deterioration) then the care should be provided and is covered by Medicare.

Note that if you need skilled nursing care to maintain your status (or to slow deterioration), then the care should be provided and is covered by Medicare. In addition, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient's care and status. In such cases, Medicare should continue to provide coverage.

When you leave a hospital and move to a nursing home that provides Medicare coverage, the nursing home must give you written notice of whether the nursing home believes that you require a skilled level of care and thus merit Medicare coverage. Once you are in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($194.50 a day in 2022). This copayment may be covered by a Medigap (supplemental) policy. After 100 days are up, you are responsible for all costs.

If you are in a nursing home and the nursing home believes that Medicare will no longer cover you, it must give you a written notice of non-coverage. The nursing home cannot discharge you until the day after the notice is given. The notice should explain how to file an expedited appeal to a Quality Improvement Organization (QIO). A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries. You should appeal right away. You will not be charged while waiting for the decision, but if the QIO denies coverage, you will be responsible for the cost. If the QIO denies coverage, you can appeal the decision to an Administrative Law Judge (ALJ). It is recommended that a patient hire a lawyer to pursue an appeal.  For an article from the Center for Medicare Advocacy on nursing home discharges, click here.

You cannot rely on Medicare to pay for your long-term care. Contact your attorney to create a long-term care plan. To find a qualified elder law attorney, click here.

For more information on Medicare, click here.

Last Modified: 01/07/2022

If your loved one needs senior rehab in a skilled nursing facility (SNF), it is crucial to know what Original Medicare covers and what costs must be paid for out of pocket.

Does Medicare Cover Long-Term Care?

Medicare is the federal health insurance program for people age 65 and over, some younger individuals with disabilities, and some individuals with end-stage renal disease. Like other health insurance plans, Medicare does not cover long-term care services.

Medicare only covers short-term stays in Medicare-certified skilled nursing facilities for senior rehab. These temporary stays are typically required for beneficiaries who have been hospitalized and are discharged to a rehab facility as part of their recovery from a serious illness, injury or operation. A few of the most common medical issues that require senior rehabilitation include pneumonia, stroke and injuries caused by serious falls.

A serious health setback that initially requires short-term care in a 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.

Medicare Rehab Coverage Guidelines

Medicare Part A (hospital insurance) pays for skilled nursing care provided in SNFs under certain circumstances. The following sections thoroughly explain Medicare rules and requirements for coverage of senior rehab care in a skilled nursing facility.

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 seniors and family caregivers. Each benefit period begins on the day that a Medicare beneficiary is admitted to the hospital on an inpatient basis. Time spent at the hospital on an outpatient or observation basis does not trigger the beginning of a benefit period. (You can find more detailed information about how Medicare distinguishes inpatient status from outpatient status and related costs at Medicare.gov.)

Once a benefit period begins, a beneficiary must then have a qualifying three-day inpatient hospital stay in order be eligible for any coverage of rehab 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 is admitted to the hospital. There is no limit to the number of benefit periods a beneficiary can have.

Patient Criteria for Medicare Rehab Coverage

In addition to the benefit period rules above, a beneficiary must meet all the following requirements:

1. The beneficiary has Medicare Part A (hospital insurance) and days left in their benefit period available to use.
2. 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.
3. 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.
4. The beneficiary’s doctor must order skilled nursing care, which requires the skills and oversight of professional personnel (e.g., registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists).
5. The beneficiary requires skilled care on a daily basis and the specific services needed must be ones that can only be provided in a SNF on an inpatient basis. (If care in a 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.)
6. The beneficiary must need skilled services for the medical condition that was treated during their qualifying three-day hospital stay or a related condition. (E.g., if you are admitted as an inpatient because you had a stroke and then break your hip while in the hospital, Medicare may cover senior rehab services for your hip even if they are no longer needed for stroke recovery.)
7. The skilled services a doctor has prescribed must be reasonable and necessary for the diagnosis or treatment of the beneficiary’s eligible condition.

How Long Does Medicare Pay for Rehab in a SNF?

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 those with Medigap policies or Medicare Advantage Plans may have additional coverage for senior rehab stays.

Costs Under the Medicare 100 Day Rule

• Days 1–20: Medicare pays the full cost for each benefit period.
• Days 21–100: Medicare pays all but a daily coinsurance. In 2022, the coinsurance is up to $194.50 per day.
• Days 101 and beyond: Medicare provides no rehab coverage after 100 days. Beneficiaries must pay for any additional days completely out of pocket, apply for Medicaid coverage, explore other payment options or risk discharge from the facility.

Breaks in Skilled Care

Sometimes beneficiaries take “breaks” from senior rehab 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, senior rehab facilities told their patients that Medicare would cease paying for skilled nursing care if their health stopped improving or had “plateaued” within their covered benefit period. However, Jimmo v. Sebelius, a 2013 federal court settlement, prompted the Centers for Medicare and Medicaid Services (CMS) 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. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.”

The current Medicare Benefit Policy Manual has reflected these clarifications since 2014, but some senior rehab facilities 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 it is possible that some of those programs haven’t caught up.

Ensuring Medicare Will Pay for Senior Rehab

There is so much room for interpretation (and reinterpretation) surrounding the rules for Medicare coverage that it is easy for families to become confused on how to pay for care in SNFs. The bottom line is that vigilance and advocacy are necessary to ensure that aging loved ones receive the skilled care they need and the coverage they are entitled to.

Family caregivers must make sure that the hospital staff and SNF staff give detailed orders and reasons for the skilled services that are needed to promote their loved ones’ health and safety. Carefully tracking the days within a benefit period can be confusing, but this is essential to prevent 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. GCMs (also known as Aging Life Care Professionals) have a great deal of experience with seniors, various types of elder care providers and Medicare. Even if your loved one has run out of Medicare coverage during their benefit period, a GCM can help you find and access other sources of financial assistance and alternative types of care.

Read: Geriatric Care Managers Can Help Busy Caregivers

Other Ways to Pay for Skilled Nursing Care

There are other sources of help available for covering skilled care and related costs. If a senior’s income and resources are limited, they may be eligible for their state’s Medicaid program. Medicaid provides assistance with paying for skilled and/or custodial care, medications, and other medical expenses. If they qualify for both Medicare and Medicaid, then they are considered a “dually eligible beneficiary” and most of their health care costs are typically covered.

Read: Qualifying for Medicaid to Pay for Long-Term Care

A Note About Medicare Rehab Coverage During the COVID-19 Pandemic

Medicare has made some changes to their coverage requirements for senior rehabilitation services during the coronavirus pandemic. Medicare beneficiaries may be able to qualify for senior rehab in a skilled nursing facility without starting a new benefit period. Others who are unable to remain in their own homes or are otherwise affected by the pandemic may be able to get care in a SNF without first having a qualifying hospital stay.

Additional information about Medicare coverage during the coronavirus pandemic is available here.