Medicare pays up to 100 days of skilled nursing facility (SNF) care if the qualifications are all met; days 1-20 in full, days 21-100 subject to $152 per day patient co-insurance (2014).
Qualifications to receive the Medicare SNF benefit:
1. it’s necessary to treat an improving medical condition AND
2. services are provided at a Medicare approved facility AND
3. the person spent at least 3 days as an admitted inpatient at a hospital. (Note: many Medicare beneficiaries that go to the hospital are coded for an observational stay, due to stricter governance by CMS over higher cost reimbursements for inpatient admissions. If a patient is coded for an observational stay, and not an inpatient admittance for at least 3 days, they are not eligible for the skilled nursing benefit. Over 1 million Medicare beneficiaries lost SNF benefit last year due to observation coding).
If a doctor places an individual in a hospital or skilled nursing facility when the kind of care the individual needs could be provided elsewhere (i.e. at home or a non-skilled care facility), the individual’s SNF stay will not be considered reasonable and necessary, and Medicare will not pay for it. If an individual stays in a hospital or skilled nursing facility longer than necessary, Medicare payments will end when inpatient care is no longer reasonable or necessary.
Although a Medicare plan may cover SNF copayments, given the qualification restrictions for the Medicare SNF benefit, Medicare beneficiaries should consider separate Short Term Care nursing facility coverage to manage the financial risk of an uncovered SNF stay.
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Qualifications to receive the Medicare SNF benefit:
1. it’s necessary to treat an improving medical condition AND
2. services are provided at a Medicare approved facility AND
3. the person spent at least 3 days as an admitted inpatient at a hospital. (Note: many Medicare beneficiaries that go to the hospital are coded for an observational stay, due to stricter governance by CMS over higher cost reimbursements for inpatient admissions. If a patient is coded for an observational stay, and not an inpatient admittance for at least 3 days, they are not eligible for the skilled nursing benefit. Over 1 million Medicare beneficiaries lost SNF benefit last year due to observation coding).
If a doctor places an individual in a hospital or skilled nursing facility when the kind of care the individual needs could be provided elsewhere (i.e. at home or a non-skilled care facility), the individual’s SNF stay will not be considered reasonable and necessary, and Medicare will not pay for it. If an individual stays in a hospital or skilled nursing facility longer than necessary, Medicare payments will end when inpatient care is no longer reasonable or necessary.
Although a Medicare plan may cover SNF copayments, given the qualification restrictions for the Medicare SNF benefit, Medicare beneficiaries should consider separate Short Term Care nursing facility coverage to manage the financial risk of an uncovered SNF stay.