When Does Medicare Pay for Skilled Nursing Services?

By Sheila Blair

Skilled nursing facilities (SNFs) have become more and more sophisticated over the years, offering more complex medical services to a much broader population beyond just the elderly.

Skilled services may be nursing-related, rehabilitative therapy-related or both, and are intended for patients who need more frequent intervention than is available with home health services. This may include, for example, patients that may require intensive short-term rehabilitative therapy services after suffering from an acute illness (such as pneumonia or stroke), a bone fracture or even surgery (such as a joint replacement).

For patients with traditional Medicare insurance, Medicare Part A will pay for up to 100 days of care in a SNF within each benefit period, if the patient:

•Has Medicare Part A (Hospital Insurance, which includes skilled nursing benefits)

•Has had a three-day inpatient hospital stay in the last 30 days. (A qualifying stay must include three midnights in the hospital and does not include observation status or visits to an ER)

•Is admitted to a SNF within 30 days of the hospitalization

•Require skilled services and has days available in a benefit period.

•The services are ordered by a physician — Such services are: Needed on a daily basis (defined as five days a week for therapy and seven days a week for nursing); are for one of the conditions that was treated during the qualifying hospital stay or for a condition that arose during the skilled stay; and are reasonable and necessary.

Medicare Part A will cover:

•A semi-private room.

•Meals.

•Skilled nursing care.

•Physical, occupational and speech-language pathology services.

•Medications.

•Medical supplies and equipment used in the facility.

•Medical social services.

•Dietary counseling.

•Ambulance transportation (to the nearest provider of necessary services not available at the SNF, if another means of transport endangers health).

Medicare Part A does not cover custodial care, which is supportive assistance with activities of daily living such as eating, bathing, dressing and using the bathroom. Medicare also will not cover private rooms, private-duty nurses, non-ambulance transportation, personal convenience items (such as beauty items, telephones and televisions), dental work, hearing aids or eyeglasses.

Patients on a Part A stay in a SNF are monitored regularly by their physician and SNF staff to ensure that all the requirements for the stay are being met. Families participate in discharge planning discussions during the admission phase of the stay, which helps SNF staff create individualized care plans and helps to identify potential needs that patients may have when they are ready to go home. For example a patient may need equipment (such as wheelchairs), safety modifications to homes, continued nursing and/or therapy intervention, or hospice services. The SNF should send families and patients a notice in writing when it is believed that Medicare will no longer cover the stay.

For more information about Medicare and help with related questions, visit www.medicare.gov and access the official Medicare handbook, Medicare & You 2012, at www.medicare.gov/Publications/Pubs/pdf/10050.pdf.