Revision 09-4; Effective December 1, 2009
Under Title XVIII of the Social Security Act, Medicare Part A coverage includes payment for limited nursing facility (NF) care as an extension of hospital care.
Medicare covers a maximum of 100 days in a skilled nursing facility (SNF), also referred to as extended care facilities. A team, consisting of physicians and nurses, determines whether the person meets Medicare's criteria for SNF at admission and at weekly reevaluations. Many persons do not use the entire 100 days, or may have hospital readmissions during their SNF period. A return to the hospital is not part of the available 100 days.
Medicare covers all charges for the first 20 days of SNF care. The following 80 days are coinsurance days. Medicare covers all of the medical expenses during this period; the person pays a coinsurance rate toward room and board. Medicare-covered services in an NF include skilled nursing care, physician services, physical/occupational/speech therapy, prescriptions, routine dental care and room and board.
For a Medicaid applicant or person who is certified for Medicare payments while in a Medicare SNF, Medicare pays the entire bill for the first through the 20th day. There is no coinsurance for that period. The person is eligible for coinsurance vendor payment beginning on the 21st day. Coinsurance continues through the 100th day if the person's stay is covered by Medicare.
A person can be certified for Medicaid during the entire SNF period, provided the person resides in a Medicaid NF. A co-payment is calculated for the coinsurance period, with vendor payment covering the balance of the SNF rate. There is no co-payment for the first 20 days of full SNF coverage.
- Begin the eligibility determination process when a person files an application for Medicaid upon admission to the Medicare-SNF part of a Medicaid facility.
- Because the person must have been in a hospital for at least three days before SNF admission, always explore prior medical coverage. Reminder: The special income limit is applicable once the person (or couple) has been confined to one or more Medicaid-approved long-term care facilities (Medicare-SNF, NF or ICF/MR) for at least 30 consecutive days.
- Accept the Medicare determination of need for SNF care as a medical necessity determination.
- The NF must submit documentation that sets the rate at which the facility is paid.
Under certain limited conditions, Medicare will pay some NF costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, the person must receive the services from a Medicare-certified SNF after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just before entering a nursing facility. This is at least three days. Care must begin within 30 days after leaving the hospital. The person’s doctor must order daily skilled nursing or rehabilitation services that the person can get only in an SNF. "Daily" means seven days a week for skilled nursing services and five days a week or more for skilled rehabilitation services.