Medicare Part A (Hospital Insurance) covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions for a limited time.
Medicare-covered services include, but aren’t limited to:
• Semi-private room (a room you share with other patients)
• Skilled nursing care
• Physical and occupational therapy*
• Speech-language pathology services*
• Medical social services
• Medical supplies and equipment used in the facility
• Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
• Dietary counseling
*Medicare covers these services if they’re needed to meet your health goal.
If you’re in a SNF but must be readmitted to the hospital, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.
People with Medicare are covered if they meet all of these conditions:
• You have Part A and have days left in your benefit period.
• You have a qualifying hospital stay.
• Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you’re in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.
• You get these skilled services in a SNF that’s certified by Medicare.
• You need these skilled services for a medical condition that was either:
• A hospital-related medical condition.
• A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.
Note: If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (for instance if you get the flu), you may be able to continue to get Medicare coverage temporarily.
Your costs in Original Medicare
• $0 for the first 20 days each benefit period.
• $148 per day for days 21-100 each benefit period in 2013.
• All costs for each day after day 100 in a benefit period.
If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.
• If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
• If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.