What does Medicare Part A cover for Skilled Nursing Facilities?
Most people who have had a family member experience skilled rehab and then transition into a nursing home are very curious on how skilled nursing facilities and the care within the facility works with Part A of Medicare. It can be extremely confusing, and if not insured properly, can be devastating to someone's finances.
Medicare Part A does cover skilled nursing care for certain conditions for a limited time for a short-term basis if all of these conditions are met, and one of those are:
- if you have Part A and have days left in your benefit period to use you have a qualifying hospital stay, which means you spend three days in the hospital for inpatient care. This would qualify you for a skilled nursing facility.
Skilled care is nursing and therapy care that can only be safely and effectively performed by or under the supervision of professionals or technician care. It's healthcare given when you need skilled rehab or skilled therapy to treat, manage, and observe your condition and evaluate your care.
These Medicare coverage services include, but aren't limited to:
- A semi-private room, which is a room you share with other patients. Many people demand a private room, which isn't covered under original Medicare.
- Meals. People aren't starved to death unless they choose not to eat in a skilled rehab.
- Skilled nursing care
- Skilled therapy - if needed to meet your health goals
- Occupational therapy, if needed
- Speech and language pathology services, if they're needed to meet your health goals
- Medical social services
- Medical supplies and equipment used in the facility
- Ambulance transportation - When other transportation endangers your health to the nearest supplier of needed services that aren't available at the skilled nursing facility, like if you had to go back to the ER
- Dietary counseling
- Swing bed services
The 3-Day Rule
The 3-day rule requires that a patient have a medical necessary three-day consecutive inpatient hospital stay, so they can receive the extended care and services needed for a skilled nursing facility.
The skilled nursing facility is an extension of care a patient needs after a hospital discharge, or it can also be provided within 30 days of the hospital stay unless admitted within 30 days is medically appropriate.
As a side note, observation services aren't covered as a part of the inpatient stay. Observation is done in the admittance when someone may be at risk, but doesn't need a full admission into the hospital. You must enter the skilled nursing facility within a short time period. Generally 30 days of leaving the hospital and require skilled services related to your hospital stay.
After you leave the skilled nursing facility, if you re-enter the same or another facility within 30 days, you don't need another three day qualifying hospital stay to get additional skilled nursing benefits. This is also true if you stop getting the skilled nursing and while in the skilled nursing, and then start getting skilled nursing again within that 30 days. So let's cover some of the key points about Medicare and the three-day rule. If your doctor has decided that you need daily skilled care, it must be given by or under the supervision of skilled nursing or therapy staff. You must get this skilled service in a skilled nursing that's certified by Medicare. You must need these skilled services for a medical condition. That's either a hospital related medical condition treated during your qualifying three-day inpatient hospital stay not including the day you leave the hospital, even if it wasn't the reason you were admitted to the hospital or a condition that started while you're getting care in the skilled nursing for a hospital-related medical condition.
For example, if you develop an infection that requires IV antibiotics, or you're getting skilled nursing care.
Now let's cover your costs for being in a skilled nursing facility.
If you only have original Medicare, most of our clients come to us knowing they want a health plan that helps cover or some of the following costs. They either want them all covered or some, for those who choose to remain on just Medicare, this is what you'll pay.
- $0 for day 0 through 20 for each benefit period
- Day 21 through 100 you're gonna pay $194.50 per day
- Days 100 and beyond you will have the joy of paying all costs.
You would normally begin to receive a form of long term care at this time within a nursing home or facility adequate to meet your needs. For those who only have a long term care insurance policy who would then begin to use that insurance to cover costs associated with their care, if needed for long term care.
So beyond a hundred days, the benefit periods beginning when you are admitted in the hospital or skilled nursing, the benefit period ends when you haven't received any inpatient care or skilled care in a skilled facility for 60 days in a row.