What is covered by Medicare in a skilled nursing facility?

Long-Term Care | Dec 21, 2014 | Hook Law Center

Many people on Medicare assume that the program will cover any medical costs they encounter, including the cost of care in a skilled nursing facility. However, coverage for care in a nursing home is actually quite limited, and it is only provided under certain circumstances.

Medicare only pays for care in a nursing facility if a patient is admitted to the facility within a month of having been admitted to a hospital for at least 3 consecutive days. In addition, Medicare requires physician certification of the fact that the necessary care can only be provided by an inpatient facility. The Centers for Medicare and Medicaid Services (CMS) must have approved the facility.

For Medicare to cover care in a skilled nursing facility, the patient must need the facility’s rehabilitation services five days a week, or its skilled nursing services seven days a week. If the care could be administered at home by a nurse on a less frequent basis, Medicare will not cover the care in a facility.

Even when care in a facility is covered, Medicare only pays for 100 days of care. For the first 20 days, full coverage is provided. From days 21 through 100, co-payment is required. After 100 days, the patient is required to pay privately until they have exhausted their resources and are eligible for Medicaid.

Medicare charges are monitored by Recovery Audit Contractors, who work for the CMS. These contractors receive a commission for detecting and recovering overpayments, so doctors and hospitals are very motivated to avoid charging Medicare for expenses that are not covered.

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