Medicare has many other criteria that must be met before it covers a stay in a skilled nursing facility. Medicare will cover skilled care only if all of the following criteria are met:
You have Medicare Part A (Hospital Insurance) and have days left in your benefit period available to use.
1. You have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. You must enter the Skilled Nursing Facility within a short period of time (generally 30 days) of leaving the hospital. After you leave skilled nursing, if you re-enter the same or another SNF within 30 days, you may not need another 3-day qualifying hospital stay to get additional SNF benefits. This is also true if you stop getting skilled care while in the SNF and then start getting skilled care again within 30 days.
2. Your doctor has ordered the services you need for SNF care, which requires the skills of professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists.
3. You require the skilled care on a daily basis and the services must be ones that can only be provided in a SNF on an inpatient basis. If you are in a SNF for skilled rehabilitation services only, your care is considered daily care even if the therapy services are offered just 5 or 6 days a week.
4. You need these skilled services for a medical condition that was treated during a qualifying 3-day hospital stay, or started while you were getting SNF care for a medical condition that was treated during a qualifying 3-day hospital stay. For example, if you are in a SNF because you broke your hip and then have a stroke, Medicare may cover rehabilitation services for the stroke, even if you no longer need rehabilitation for your hip.
5. The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.
How long will Medicare cover a stay in a Skilled Nursing Facility?
The amount Medicare covers depends on how long you stay in skilled nursing. Here is a breakdown of Medicare coverage:
Days 1 – 20
Medicare pays the full cost
Days 21 – 100
Medicare pays all but a daily co-pay. (In 2015, the copayment is up to $157.50 coinsurance per day.)
After 100 days
Medicare provides no coverage after 100 days.
If you have a Medigap policy or are in a Medicare Advantage Plan, you may have additional coverage.