Medicare Part A offers a skilled nursing facility benefit.
Medicare pays all costs for the first 20 days and a portion of costs for days 21 through 100.
On day 101, the person is responsible for all costs.
Skilled nursing care includes occupational and physical therapy and other services that help a person improve or maintain their condition.
Medicare will not pay solely for custodial care, such as help bathing and dressing.
Whether you’ve had surgery, a recent hospital stay or a health setback, skilled nursing facility care can help you make the transition between hospital and home. Medicare covers skilled nursing facility care under Part A. Medicare has distinct rules about where you can stay, how long, and what you’ll pay. Keep reading to find out how you can get skilled nursing facility care through Medicare.
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Medicare pays for skilled nursing care at varying levels from Days 1 to 100 of your stay. Here’s the breakdown for 2024:
Days 1 through 20: You pay $0 in this benefit period.
Days 21 through 100: You pay $204 coinsurance each day of the benefit period.
Days 101 and forward: You pay all costs.
To qualify for skilled nursing care, you must first have a hospital stay that lasts at least three consecutive days. You will then enter the skilled nursing facility usually within 30 days of leaving an inpatient care facility.
Skilled nursing care involves health services you could only receive from licensed medical professionals. Facilities that offer skilled nursing care do more than provide for activities of daily living (such as bathing, dressing or feeding). They provide care that helps you improve your medical condition. Examples of skilled nursing care services include wound care and physical therapy.
Services that Medicare provides under Part A as part of your stay at a skilled nursing facility include the following:
- Dietary counseling
- Medical supplies/equipment
- Occupational therapy
- Physical therapy
- Speech-language pathology
- Transportation, including ambulance transportation if other methods are not safe
Medicare also pays for a semi-private room at the skilled nursing facility.
What Qualifies as a Skilled Nursing Facility?
Skilled nursing facilities offer care from licensed medical professionals. The facility and its providers must participate in Medicare for the costs to be covered. You can find a list of skilled nursing facilities in your area by visiting Medicare.gov and entering your zip code and desired facility type (such as long-term care or inpatient rehabilitation).
If you have Original Medicare, you can receive care at any skilled nursing facility that accepts Medicare. If you participate in a Medicare Advantage plan, you may save the most money by choosing a skilled nursing facility in your network. However, all Medicare Advantage plans must offer some skilled nursing facility benefit to their enrollees because they must offer the same services as Original Medicare.
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Medicare covers skilled nursing care for up to 100 days per benefit period. Skilled nursing care must be doctor-prescribed and intended to help you improve, monitor or manage your medical condition. Skilled nursing is typically a short-term need before you can return home or to a long-term care facility.
Differences exist between skilled nursing services and custodial care (care provided by non-medical aides). The table below illustrates the differences between skilled nursing and custodial care.
- Intravenous injections
- Occupational therapy
- Physical therapy
- Speech-language services
- Wound care
- Administering eye drops
- Catheter care
- Using the bathroom
While you may receive some custodial care services while in a skilled nursing facility, Medicare doesn’t cover custodial care services alone.
Medicare Part B is the Medicare portion that pays for outpatient medical care, including doctor’s visits, some immunizations and emergency room visits. Part A pays for inpatient medical care, like skilled nursing facilities.
However, it’s possible that a person may still pay for Part B services while in a skilled nursing facility. Medicare limits Part B billing to very specific services while a person is in a skilled nursing facility to reduce risk of fraud. Examples of Part B services a person may receive during a skilled nursing facility stay include:
- Physician outpatient visits.
- Ambulance transportation to appointments (if needed), such as dialysis.
- Administration of certain medications, such as chemotherapy or erythropoietin for dialysis.
- Custom prosthetic devices, such as artificial limbs.
Most other services are billed under Medicare Part A.
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The Medicare 100 Day Rule refers to the fact Medicare will pay at least a portion of your care for the first 100 days (per benefit period) you are in a skilled nursing facility. A benefit period begins the first day you are admitted as an inpatient in a hospital or a skilled nursing facility. The benefit period ends when you have not been in a facility for 60 consecutive days.
You can have more than one benefit period in a year. After being released for 60 days, if you are hospitalized again, you will be in a new benefit period. However, if you are re-admitted to the hospital or a skilled nursing facility before 60 days, you will be within the same benefit period.
After 100 days, Medicare no longer pays for any portion of skilled nursing facility care. Medicare considers skilled nursing facility care “short-term” care needed to help a person recover and improve their health. Ideally, by the 100-day mark, a person should be able to make a transition back to home or custodial care.
While in a skilled nursing facility, your doctor and treatment team will outline a care plan. Your treatment plan will review the plan daily to ensure you are meeting or working toward care goals. The team will re-evaluate your plan at designated times to try and ensure your timely discharge.
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