Coverage in a Skilled Nursing Facility

By Kendra Knouff
eMedicareSupplements Senior Writer

For Medicare beneficiaries, Medicare Part A will cover up to 100 days of skilled nursing care in a facility per each period of illness. Skilled nursing care is a level of care ordered by a physician and provided by, or under the supervision of, a professional, such as a physical therapist, registered nurse or licensed practical nurse on a daily basis. It is important to not that the requirements for receiving Medicare coverage for skilled nursing facility care are quite rigid. They include:

• The Medicare beneficiary must enter a skilled nursing facility no more than 30 days after being discharged from a hospital (as an inpatient; “Observation Status” is not considered). The stay must have lasted at least three days, not including the day of discharge.
• The beneficiary must receive care in the skilled nursing facility for the same condition that caused the prior hospitalization.
• The beneficiary must receive a skilled level of care that cannot be given at home or in an outpatient facility (or on an outpatient basis). Unfortunately, most nursing home residents do not receive this level of care.

When the skilled nursing facility determines that the beneficiary no longer needs or is no longer receiving a skilled level of nursing, Medicare coverage ends. Also, on the 21st day in a skilled nursing facility, the beneficiary must pay a substantial co-payment equaling one-eighth the initial hospital deductible ($141.50 per day). This co-payment is usually covered by Medicare supplemental insurance if the beneficiary has a Medicare Supplement Plan.

A new period of illness begins when the beneficiary has not received skilled care, either in a skilled nursing facility or hospital, for 60 consecutive days. The beneficiary can remain in a skilled nursing facility and still qualify as long as he or she has not received a skilled level of care during that 60-day period.