Skilled nursing facility care
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services
(Clinical Guidelines 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 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]
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
- Medi-Cal Nursing Home, Long Term Care & Estate Recovery
- Medi Cal IHSS In Home Support Services
- Home Health & Long Term Care
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