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Medicare in Skilled Nursing Facilities

The following information was put together with the help of the 1997 Guide to Health Insurance for People with Medicare and was updated December 2008. For the most up-to-date information on Medicare, visit their website or call 1-800-MEDICARE.

WHAT IS MEDICARE?

Medicare is a national health insurance program for people 65 years of age and older, certain younger disabled people, and people with permanent kidney failure. Medicare is run by the Health Care Financing Administration. The Social Security Administration helps HCFA by enrolling people in Medicare and by collecting Medicare premiums.

Two Parts of Medicare

Medicare is divided into two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). Part A helps pay for care in a hospital and a skilled nursing facility, and for home health and hospice care. Part B helps pay doctor bills, outpatient hospital care and other medical services not covered by Part A. Your Medicare card shows the Medicare coverage you have--Hospital Insurance (Part A), Medical Insurance (Part B), or both--and the date your coverage started.

Skilled Nursing Facility Care

Medicare Part A can help pay for up to 100 days of skilled care in a skilled nursing facility during a benefit period. All covered services for the next 80 days are paid by Medicare, except for a daily coinsurance amount. The daily coinsurance is $124.00. You are responsible for the coinsurance." with this " All covered services for the next 80 days are paid by Medicare, except for a daily coinsurance amount. The daily coinsurance for 2009 is $133.50. You are responsible for the coinsurance. If you require more than 100 days of care in a benefit period, you are responsible for all charges beginning with the 101st day.

A skilled nursing facility is different from a nursing home. It is a special kind of facility that primarily furnishes skilled nursing and rehabilitation services. It may be a separate facility, or a distinct part of another facility such as a hospital.

Medicare will not pay for your stay if the services you receive are primarily personal care or custodial services such as assistance in walking, getting in and out of bed, eating, dressing, bathing and taking medicine. Medicare does not pay for custodial care if that is the only kind of care you require.

To qualify for Medicare-covered skilled nursing facility (SNF) benefits, you must:

Require daily skilled care which, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
Be in the hospital for at least three consecutive days (not counting the day of discharge) before entering a skilled nursing facility that is certified by Medicare.
Be admitted to the skilled nursing facility for the same condition for which you were treated in the hospital.
Generally be admitted to the facility within 30 days of a discharge from the hospital.
Be certified by a medical professional as needing skilled nursing or skilled rehabilitation services on a daily basis.

It is important to note that not all medical conditions qualify for 100 days of coverage. Also, some diagnosis that do qualify, do not automatically provide a person coverage for 100 days on Medicare. The key word is "skilled" and maintaining a person's "skilled" needs at the nursing facility. For example, a person admitted to a nursing facility with a fractured hip may require skilled services initially, but improve to the point of no longer needing them and hence, since skilled coverage cannot be maintained, Medicare A coverage stops at this point.

Gaps in Skilled Nursing Facility Coverage You Pay:

$133.50 daily coinsurance for days 21 through 100 in each benefit period.
All costs after 100 days in a benefit period.
All costs for care that is less than the level of care Medicare covers in a skilled nursing facility.
All costs if you were not transferred to the skilled nursing facility in a timely manner after a qualifying hospital stay.
For care in a general nursing home, or in a skilled nursing facility not approved by Medicare, or for just custodial care in a Medicare-approved skilled nursing facility.


   

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