Skilled nursing facility care
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services
(Clinical Guidelines – Oscar – Explains Medical Necessity Requirements so much better and in logical order!)
and supplies furnished in a skilled nursing facility after a 3-day minimum, medically necessary, inpatient hospital stay Medicare Policy Manual * Publication 10153 SNF * for a related illness or injury. An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to help improve or maintain your current condition.
A SNF is a care center where nurses and nursing assistants are available to provide twenty-four hour care for patients to assist them with conditions in their transition between the hospital and a lower level of care such as the home. A SNF may also provide rehabilitation in order to improve the member’s function and decrease the burden of care. Oscar Clinical Bulletin *
To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous injections or physical therapy) which, as a practical matter, can only be provided in a skilled nursing facility if you’re an inpatient.
- Nothing for the first 20 days of each benefit period
- $185 Coinsurance per day for days 21–100 of each benefit period
- Sample Medicare Advantage Copay
- Medicare Advantage must pay at least as well and same qualifications as Original Medicare.
- MAPD can’t do “funny stuff” or they can get busted for Risk Adjustment Fraud
- Sample Medi Gap
- All costs for each day after day 100 in a benefit period Medicare.Gov SNF *
Medicare doesn’t cover long-term care or custodial care.
The beneficiary needs daily skilled care or rehabilitation services as ordered by a physician. These skilled services can only be rendered by, or under the direct supervision of, skilled nursing or rehabilitation staff. In addition, the skilled services the patient receives must be for a medical condition they were treated for during the three-day qualifying hospital stay, or for a condition that arose during that hospital stay or while the patient was receiving Medicare-covered SNF care.
The requirement of “daily” skilled services should not be taken so literally that occasional sessions missed due to holidays or illness will make the patient not meet the daily requirement for skilled services.
See Oscar’s Clinical Guidelines – It’s explained so much better!
30.6 – Daily Skilled Services Defined
Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7-days-a week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. (If therapy services are provided less than 5 days a week, the “daily” requirement would not be met.)
A patient who normally requires skilled rehabilitation services — See Medicare Benefit Policy Manual Chapter 8 –Coverage of Extended Care (SNF) Services Under Hospital Insurance
Don’t qualify for Skilled Nursing?
Check out the True Freedom Home Health Plan – BEFORE you need it.
Resources & Links
- Skilled nursing facility care coverage (Medicare.Gov)
- Get help paying for skilled nursing facility care
- Medi Cal IHSS In Home Services
- Medi Cal – Medically Needy – Share of Cost
- Medi Cal – Qualification & Estate Recovery
- Medi Cal has 90 day look back on claims from date you applied
- Our webpage on Home Health & Long Term Care
- 7 ADL’s Activities of Daily Living to trigger Long Term Care
- Veterans Administration?
- Find hospitals & skilled nursing facilities
- Booklet on this page to finding Nursing Homes
- Pamphlet on Skilled Nursing from Medicare
- Hospice, Palliative & Respite Care
- Medicare Benefit Policy Manual Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance
- Social Security – Benefits for Surviving Spouse & Dependent Children
Email us [email protected]
(Clinical Guidelines Explained so much better and in logical order!)
- Medicare's VIDEO Nursing Home / Long-Term Care
- Our Webpage on Long Term Care
Medicare #Appeals 11525
Filing an appeal with Medicare
Home health services
You can use your home health benefits under Part A and/or Part B to pay for home health services. Medicare covers medically necessary part-time or intermittent skilled nursing care, and/or physical therapy, speech-language pathology services, or continued occupational therapy services. A doctor, or certain health care professionals who work with a doctor, must see you face to-face before a doctor can certify that you need home health services. A doctor must order your care, and a Medicare-certified home health agency must provide it.
Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means:
• You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
• Leaving your home isn’t recommended because of your condition.
• You’re normally unable to leave your home because it’s a major effort.
You pay nothing for covered home health services. You pay 20% of the Medicare-approved amount, and the Part B deductible applies, for Medicare covered medical equipment. copied from Medicare & You – see brochure in side panel *
Home Health Official Booklet
- Resources on our websites - mentioned in the pamphlet
- Get Quote - Proposal for Long Term Care
- Borden Hamman Long Term Planning Guide
- Our webpages on
This government provided tool also allows you to see what insurances and public benefits are accepted at the various facilities.
Private – Individual Long Term Care Coverage.
Here’s a 7 page Checklist to help keep track in your search. Hopefully, you don’t need all the services of a nursing home here’s Alternatives to Nursing Home Care.
We’ve also included all the helpful and relevant publications and information we could find on this page and others in this website. Use the menu at top or embedded links to navigate and find the information that you need.
Resources & Links
Veteran’s Home Health Care va.gov
Health Grades.com – they charge a fee
Poorest Nursing Homes
Prevent & Report Elder Abuse CA Attorney General
Law Help Nursing Homes & Residential Care Facilities Nursing Home Bill of Rights CA Deptment of Public Health pdf 39 pages
Code of Federal Regulations (C.F.R.), 42 CFR 483.12
Physician’s Report for Residential Care Facilities for the Elderly (RCFE) Preplacement Appraisal Information LIC 603 Identification and Emergency Information LIC 601 Senate Reviews Assisted Living Facility Problems 2.2014 CA Health Line
SB 411 2012 – Price – Licensing of Home Care Agencies & Workers AB 889 Ammiano – 2012 Domestic Workers New Life Styles.com – The source for Senior Living
offer persons 60 years of age or older a long term continuing care contract that provides for independent living units, residential care/assisted living services, and skilled nursing care, usually in one location, and usually for a resident’s lifetime. Most CCRCs require a substantial entrance fee (e.g., from a low of $100,000 to over a million) to be paid by the applicant upon admission along with monthly fees. * CANHR.org *
View our pages on Long Term Care
- Activities of Daily Living
- Can’t afford premiums or not medically qualified
- Employer Groups – Long Term Care
- Life Insurance vs Lump Sum Payment
- Mutual of Omaha LTC
- Nursing Homes – Assisted Living – Finding and Selecting the best ones