Coverage for skilled nursing facilities (also known as SNFs for short) is provided by Medicare Part A. Medicare includes coverage in a SNF under certain situations for limited time periods.
It is crucial that you understand what those conditions and time periods are to ensure that your stay in a SNF is Medicare-covered. You’ll also want to know what costs you may still incur as a Medicare beneficiary that needs care offered by a SNF.
What Services Does Medicare Part A Cover in a Skilled Nursing Facility?
Medicare covers most aspects of a stay in a skilled nursing facility. A list of Medicare-covered services includes:
- Skilled nursing care
- A semi-private room
- Physical and/or occupational therapy
- Speech-language pathology services
- Social services
- Medical equipment and supplies
- Ambulance transportation, if medically necessary, to the nearest provider of needed services not offered at your SNF.
Supplemental Coverage Makes Skilled Nursing Facility Admissions Much Easier
Important to note: the costs below pertain to someone who has coverage through Medicare Part A only. If you have additional supplemental coverage through a Medigap policy, most plans cover the SNF daily copayments that you incur on days 21-100. If you have a Medicare Advantage plan, your coverage and costs may vary from what is offered under traditional Medicare, and you should review your plan’s unique “Summary of Benefits” to determine what coverage it offers.
Medicare Part A Skilled Nursing Facility Coverage Criteria
You are covered by Medicare Part A if your stay in a SNF meets the following conditions:
- You are enrolled in Medicare Part A and have days remaining in your “benefit period.” A benefit period begins the day you are admitted to a hospital or a SNF. It ends when you have not received hospital or SNF care for 60 days in a row. After that period ends, if you were to have to go back to a hospital or SNF, a new benefit period would start.
- Your stay in a SNF must be preceded by a qualifying hospital stay (3 or more days as an inpatient), must start within 30 days of leaving the hospital and must be for the same condition(s) for which you were hospitalized.
- The SNF must be certified by Medicare (find Medicare-certified SNFs).
- Your doctor must believe you need the daily skilled care provided by a SNF, and
- Your reason for needing skilled care in a SNF must be related to the qualifying hospital stay or be the result of a condition that started while you were hospitalized or getting care in a SNF.
If you meet the above criteria, your stay in a SNF would be Medicare-covered.
What Are Your Costs for a Medicare-Covered Stay in a Skilled Nursing Facility in 2020?
Medicare Part A provides coverage for a Medicare-covered skilled nursing facility stay. However, this does not mean that you are covered at 100% for all costs indefinitely. As with other parts of Medicare and other services, there are some out-of-pocket costs.
For days 1-20 of a Medicare-covered SNF stay, Medicare covers the full amount of the stay with no out-of-pocket costs to the Medicare beneficiary.
After day 20, for days 21-100, you would be responsible for a daily copayment of $176 per day.
After day 100, there is no Medicare coverage for a SNF and you would be responsible for all costs.
If you have a break in SNF care that lasts 60 days or more, your benefit period would reset. This means that Medicare coverage for SNF benefits is reset, and the maximum coverage available would be 100 days for a new stay in a SNF.
However, it’s worth noting that although Medicare will pay for up to 100 days, that does not mean it will approve a stay of 100 days for everyone. The average Medicare length of stay in 2013, for example, was just 28 days.