How to Cover Skilled Nursing with Medicare

Navigating the complexities of healthcare, especially as we age, can be daunting. One area that often causes confusion is the coverage of skilled nursing facilities (SNFs) under Medicare. This comprehensive guide aims to demystify how Medicare covers skilled nursing care, providing you with clear, actionable information to make informed decisions for yourself or your loved ones. We’ll dive deep into eligibility, covered services, costs, the critical distinction between skilled nursing and custodial care, and what to do if your coverage is denied.

Understanding Skilled Nursing Care: More Than Just a “Nursing Home”

Before we delve into Medicare’s role, it’s crucial to differentiate between a “nursing home” and a “skilled nursing facility.” While these terms are often used interchangeably, their implications for Medicare coverage are vastly different.

A Skilled Nursing Facility (SNF) provides a high level of medical care that can only be safely and effectively performed by, or under the supervision of, licensed healthcare professionals. This care is generally short-term and aims to help a patient recover from a serious illness, injury, or surgery. Think of it as a bridge between a hospital stay and returning home, or transitioning to a lower level of care. Examples of skilled care include:

• Intravenous (IV) injections or medications: Administering drugs directly into the bloodstream.

• Complex wound care: Dressing changes, debridement, and monitoring of difficult wounds.

• Physical therapy: Intensive rehabilitation to regain strength, mobility, and balance after an injury or surgery (e.g., hip replacement, stroke).

• Occupational therapy: Helping patients relearn daily activities like dressing, bathing, and eating.

• Speech-language pathology services: Addressing swallowing difficulties (dysphagia) or communication impairments after a stroke.

• Monitoring of vital signs and unstable medical conditions: For patients requiring close observation and management.

• Tube feedings: Administering nutrition or medication through a feeding tube.

Conversely, a “nursing home” typically refers to a facility that provides long-term care, primarily focusing on assistance with Activities of Daily Living (ADLs) such as bathing, dressing, eating, toileting, and transferring. This is known as custodial care. While nursing homes may offer some skilled services, their primary purpose is to provide ongoing personal care for individuals who cannot safely live independently due to chronic conditions, disabilities, or cognitive decline. Medicare generally does NOT cover long-term custodial care. This distinction is paramount when considering Medicare coverage for a facility stay.

The Foundation of Coverage: Medicare Part A

The primary component of Medicare that covers skilled nursing facility care is Medicare Part A (Hospital Insurance). Part A is designed to cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services.

Key Requirements for Medicare Part A SNF Coverage

To qualify for Medicare Part A coverage for a skilled nursing facility stay, you must meet all of the following conditions:

1. Qualifying Inpatient Hospital Stay: This is perhaps the most critical requirement. You must have had a qualifying inpatient hospital stay of at least three consecutive days.
   • What counts: The day you are formally admitted as an inpatient to a hospital counts. Days spent in the emergency room or under “observation status” (even if you stay overnight) generally do not count towards the three-day requirement. It’s vital to confirm with the hospital whether you are admitted as an inpatient.

   • Purpose: This rule ensures that your SNF stay is a direct continuation of necessary medical care following an acute hospital admission.

   • Example: John, 78, falls and breaks his hip. He is admitted to the hospital as an inpatient for surgery and spends four days recovering. This qualifies as a three-day inpatient hospital stay. After his hospital discharge, he needs intensive physical therapy to regain mobility. His doctor recommends a skilled nursing facility.

2. Timely Admission to a Medicare-Certified SNF: You must be admitted to a Medicare-certified skilled nursing facility within a short time frame, generally 30 days, of leaving the hospital.

   • Medicare-Certified: The facility must be approved by Medicare to provide skilled nursing care. You can verify this on Medicare.gov/care-compare or by asking the facility directly.

   • Example: Following his hip surgery, John is discharged from the hospital on a Friday. His family arranges for his admission to a Medicare-certified SNF the following Monday, well within the 30-day window.

3. Need for Daily Skilled Care: Your doctor must certify that you need daily skilled nursing care or skilled therapy services. This care must be administered by or under the supervision of skilled nursing or therapy staff.

   • “Daily” is crucial: This means you require skilled services seven days a week for nursing care, or at least five days a week for therapy services.

   • Improvement or Maintenance: The skilled care must be necessary to treat, manage, and observe your condition, and to evaluate your care. It aims to improve your condition, maintain your current condition to prevent it from worsening, or prevent or delay deterioration.

   • Example: John’s doctor determines he needs daily physical therapy and skilled wound care for his incision. This meets the “daily skilled care” requirement. If John only needed help with bathing and dressing, it would likely be considered custodial care and not covered by Medicare.

4. Connection to Hospital Stay: The skilled services you receive in the SNF must be for a condition that was treated during your qualifying inpatient hospital stay, or for a new condition that started while you were receiving Medicare-covered SNF care for the original condition.

   • Example: John’s physical therapy and wound care are directly related to his hip fracture and surgery, which were the reasons for his hospital stay.

The Benefit Period: Your Coverage Clock

Medicare measures your use of hospital and skilled nursing facility services in benefit periods. Understanding this concept is key to knowing how much coverage you have and when your benefits might reset.

• Start of a Benefit Period: A benefit period begins the day you are admitted as an inpatient in a hospital or a skilled nursing facility.

• End of a Benefit Period: A benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.

• New Benefit Period: If you go into a hospital or SNF after one benefit period has ended, a new benefit period begins. There’s no limit to the number of benefit periods you can have.

Important Note: You must pay the inpatient hospital deductible for each new benefit period.

What Medicare Part A Covers in a SNF (and for how long)

If you meet all the eligibility criteria, Medicare Part A covers a wide range of services in a Medicare-certified SNF:

• Semi-private room: A room you share with other patients. (Private rooms are generally not covered unless medically necessary).

• Meals: Provided by the facility.

• Skilled nursing care: Provided by registered nurses (RNs) and licensed practical nurses (LPNs).

• Physical therapy (PT): To improve movement and strength.

• Occupational therapy (OT): To help with daily activities.

• Speech-language pathology services (SLP): For communication and swallowing.

• Medical social services: Counseling and planning for discharge.

• Medications: Administered within the facility.

• Medical supplies and equipment: Used in the facility.

• Dietary counseling: As needed.

• Ambulance transportation: If medically necessary to the nearest supplier of services not available at the SNF.

The 100-Day Coverage Limit and Cost-Sharing

Medicare Part A coverage for a skilled nursing facility stay is limited to 100 days per benefit period. The cost-sharing structure changes based on the length of your stay:

• Days 1-20: Medicare Part A pays 100% of the approved costs. You pay nothing.
  • Example: John stays in the SNF for 15 days. Medicare covers the entire cost, and John pays $0.
• Days 21-100: You pay a daily coinsurance. In 2025, this amount is determined annually by Medicare. (For reference, it was $209.50 per day in 2025). Medicare Part A pays the remaining approved costs.
  • Example: John needs to stay for 45 days. For the first 20 days, he pays nothing. For days 21 through 45 (25 days), he will be responsible for the daily coinsurance amount. If the 2025 coinsurance is $209.50, his total for these 25 days would be $209.50 * 25 = $5,237.50.
• Days 101 and beyond: Medicare Part A provides no coverage for skilled nursing facility care after day 100 in a benefit period. You are responsible for 100% of the costs.
  • Example: If John needed to stay for 105 days, he would pay nothing for days 1-20, the daily coinsurance for days 21-100, and the full cost for days 101-105.

It’s crucial to track your days in an SNF to avoid unexpected costs. The facility should also keep you informed.

When Medicare Part A SNF Coverage Ends

Your Medicare Part A coverage for skilled nursing facility care can end for several reasons, even before you reach the 100-day limit:

1. You no longer require daily skilled care: This is the most common reason. If your medical condition improves to the point where you no longer need daily skilled nursing or therapy services, Medicare will stop covering your stay. For instance, if you only need assistance with daily living activities (custodial care) and not specialized medical care, Medicare coverage will cease.
   • Example: After 60 days, John has made significant progress in physical therapy and can safely manage his mobility with minimal assistance. His doctor determines he no longer requires daily skilled physical therapy. Medicare coverage would likely end at this point.
2. You leave the SNF: If you are discharged from the SNF, your current benefit period will eventually end if you remain out of the facility (and hospital) for 60 consecutive days.

3. You reach the 100-day limit: As explained, Medicare Part A coverage for SNF care is capped at 100 days per benefit period.

What happens if coverage ends? If Medicare stops paying, you become responsible for the full cost of your stay. At this point, you might explore other payment options, such as:

• Medicaid: If you meet low-income and asset requirements, Medicaid can often cover long-term nursing home care.

• Long-Term Care Insurance: If you have a private long-term care insurance policy, it may cover some or all of the costs once Medicare coverage ends.

• Private Pay: You pay for the care out of your own pocket.

Medicare Advantage Plans and SNF Coverage

If you have a Medicare Advantage Plan (Part C), your coverage for skilled nursing facilities will be handled differently than with Original Medicare. Medicare Advantage plans are offered by private insurance companies approved by Medicare, and they must cover at least everything that Original Medicare (Parts A and B) covers.

However, Medicare Advantage plans can have their own rules and networks:

• Network Restrictions: Most Medicare Advantage plans have a network of preferred providers and facilities. You may be required to use a Medicare-certified SNF within your plan’s network, or you may pay higher costs for out-of-network care.

• Prior Authorization: Many Medicare Advantage plans require prior authorization for SNF stays, and for continued care after a certain period (e.g., after the first 20 days). This means the plan must approve your stay and ongoing treatment for it to be covered.

• Cost-Sharing: While they must cover the same services, Medicare Advantage plans can have different deductibles, copayments, and coinsurance amounts than Original Medicare. It’s crucial to review your specific plan’s Evidence of Coverage (EOC) document to understand your financial responsibilities.

• Benefit Design: Some Medicare Advantage plans may offer additional benefits related to skilled nursing or post-acute care that Original Medicare does not, such as expanded home health services.

Actionable Advice for Medicare Advantage Users:

• Contact your plan before admission: Always call your Medicare Advantage plan directly or refer to your plan’s documents to confirm coverage, network requirements, and any necessary prior authorizations for an SNF stay.

• Understand your costs: Ask about your specific copayments or coinsurance for skilled nursing care, especially for days 21-100.

When Your Skilled Nursing Coverage is Denied or Ends Prematurely: Your Appeal Rights

It’s a common scenario: you’re in an SNF, recovering, and suddenly receive a notice that Medicare will no longer cover your stay because you no longer meet the “daily skilled care” requirement, or your Medicare Advantage plan denies continued coverage. This can be incredibly stressful, but you have significant appeal rights.

Fast Appeal Process (Expedited Review)

If you believe your skilled nursing services are ending too soon, or you’re being discharged prematurely, you have the right to a fast appeal (expedited review). This is crucial because it allows you to remain in the SNF while the appeal is reviewed, without immediate financial liability (though you might be responsible for costs if the appeal is denied).

Steps for a Fast Appeal:

1. Receive Notice of Medicare Non-Coverage (NOMNC): The SNF must provide you with a written notice called the “Notice of Medicare Non-Coverage” at least two days before your Medicare-covered services are scheduled to end. This notice explains your right to a fast appeal.

2. Contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO): This independent organization reviews appeals for Medicare. The NOMNC will provide their contact information. You must contact the BFCC-QIO by noon of the calendar day before your coverage is set to end.

3. BFCC-QIO Review: The BFCC-QIO will review your medical records and the information from the SNF. They will make a decision within 72 hours of receiving all necessary information.

4. Decision:

   • If the QIO sides with you: Medicare coverage will continue.

   • If the QIO sides with the SNF: You will be responsible for the costs starting two days after the NOMNC was issued, or from the date the SNF said coverage would end (whichever is later). You still have further appeal rights.

5. Detailed Explanation of Non-Coverage: If the QIO upholds the termination, the SNF must provide you with a “Detailed Explanation of Non-Coverage” explaining why your services are no longer covered.

Standard Appeal Process (for Denials of Payment or Services Already Received)

If you’ve already paid for services that you believe should have been covered by Medicare, or if your fast appeal was denied, you can pursue the standard Medicare appeals process. This process has multiple levels:

1. Redetermination (First Level): You (or your representative) request a review by the Medicare Administrative Contractor (MAC) that processed the original claim. You must submit this request within 120 days of receiving your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB).

2. Reconsideration (Second Level): If you disagree with the Redetermination decision, you can request a Reconsideration by a Qualified Independent Contractor (QIC). You have 60 days from the Redetermination decision to file this.

3. Administrative Law Judge (ALJ) Hearing (Third Level): If the QIC upholds the denial, you can request a hearing before an Administrative Law Judge. There’s a minimum dollar amount in controversy required for an ALJ hearing, which changes annually. You have 60 days to request this hearing.

4. Medicare Appeals Council Review (Fourth Level): If you disagree with the ALJ decision, you can request a review by the Medicare Appeals Council.

5. Judicial Review in Federal District Court (Fifth Level): As a final step, if the Medicare Appeals Council denies your appeal, you may be able to file a lawsuit in federal court. This also has a minimum dollar amount in controversy.

Tips for Appeals:

• Act quickly: Pay close attention to deadlines for each appeal level.

• Gather documentation: Keep all notices, medical records, and communication related to your SNF stay and coverage.

• Get help: Organizations like your State Health Insurance Assistance Program (SHIP) can provide free counseling and assistance with Medicare appeals. A patient advocate or legal counsel specializing in Medicare can also be invaluable.

• Clearly explain your case: In your appeal, explain precisely why you believe the services were medically necessary and should be covered. Provide supporting documentation from your doctor or other healthcare providers.

Planning for Potential Skilled Nursing Needs

While we hope to avoid needing skilled nursing care, proactive planning can alleviate significant stress and financial burden if the need arises.

Understanding Your Insurance Landscape

• Original Medicare (Part A & B): If you have Original Medicare, understand the 100-day limit and the coinsurance for days 21-100.

• Medigap (Medicare Supplement Insurance): Many Medigap plans help cover the daily coinsurance for skilled nursing facility stays from days 21-100, significantly reducing your out-of-pocket costs. If you have Original Medicare, a Medigap plan is a highly recommended consideration for this reason. They do not cover the costs after day 100.

• Medicare Advantage (Part C): As discussed, review your plan’s specific SNF coverage details, network requirements, and prior authorization rules.

• Long-Term Care Insurance: For expenses beyond Medicare’s 100-day limit, especially for custodial care, a separate long-term care insurance policy can be invaluable. These policies are purchased independently and have their own premiums, waiting periods, and benefit limits.

Choosing a Medicare-Certified Skilled Nursing Facility

• Medicare.gov/Care-Compare: This official Medicare website allows you to search for Medicare-certified nursing homes (which often include SNFs) in your area and compare their quality ratings, health inspection results, staffing levels, and quality measures.

• Ask for Recommendations: Consult your doctor, hospital discharge planner, or social worker for recommendations. Friends, family, and trusted community members can also offer insights.

• Visit Facilities: If possible, visit facilities you are considering. Pay attention to the cleanliness, staff interaction with residents, the overall atmosphere, and the types of therapy and activities offered.

• Inquire About Services: Confirm that the facility provides the specific skilled services you or your loved one will need.

• Understand Discharge Planning: Ask about the facility’s discharge planning process and how they assist patients in transitioning back home or to a lower level of care.

The Role of Discharge Planners and Social Workers

When you are hospitalized, the hospital’s discharge planner or social worker plays a critical role in coordinating your post-hospital care, including identifying appropriate skilled nursing facilities. They can:

• Assess your needs: Determine if you meet the criteria for skilled nursing care.

• Provide a list of Medicare-certified SNFs: That can meet your medical needs.

• Help with placement: Assist in finding an available bed and coordinating transfer.

• Explain your rights: Inform you about Medicare coverage rules and your appeal rights.

It’s vital to engage with these professionals early in your hospital stay to ensure a smooth transition and understanding of your options.

Common Misconceptions and Clarifications

Let’s address some common misunderstandings about Medicare and skilled nursing facilities:

• Medicare does NOT pay for indefinite nursing home stays: Medicare’s coverage for skilled nursing is explicitly short-term, medically necessary, and rehabilitative, not for long-term custodial care.

• “Observation status” in the hospital can be costly: If you spend days in the hospital under observation rather than as a formally admitted inpatient, those days will not count towards your three-day qualifying hospital stay, potentially disqualifying you from SNF coverage. Always confirm your admission status with hospital staff.

• You don’t need to be completely recovered: Medicare coverage can end even if you haven’t fully recovered, as long as you no longer require daily skilled care. The goal is to reach a point where you can safely manage your care at a lower level of intensity or at home.

• A new diagnosis doesn’t automatically restart benefits: While a new condition that develops during a Medicare-covered SNF stay might be covered, simply having a new diagnosis outside of that context doesn’t automatically grant you a fresh 100 days if your prior benefit period has already ended or your skilled need has ceased. To qualify for a new benefit period, you generally need to have been out of a hospital or SNF for 60 consecutive days, followed by a new qualifying inpatient hospital stay.

Conclusion: Empowering Your Healthcare Journey

Navigating skilled nursing facility coverage with Medicare requires a clear understanding of the rules, a proactive approach to planning, and vigilance in advocating for your rights. Medicare Part A is a crucial safety net for short-term, medically necessary skilled care following a hospital stay, but it’s not a solution for long-term custodial needs.

By grasping the eligibility criteria, the 100-day limit, the critical distinction between skilled and custodial care, and your appeal options, you can approach potential skilled nursing needs with confidence and clarity. Arm yourself with information, ask pertinent questions, and don’t hesitate to seek assistance from Medicare resources and patient advocates. Your ability to make informed decisions directly impacts the quality and affordability of your care journey.