What does Medicare Cover in a Skilled Nursing Facility?

You or a family member have a serious health event like a stroke or a broken hip and are admitted to the hospital. Rehabilitation services are needed. What will Medicare cover?

Medicare will cover skilled nursing and rehabilitation services, that is medically necessary services ordered by a physician and performed by a physical therapist, occupational therapist or other skilled professional, under Medicare Part A.

To qualify for the coverage the patient must meet the following criteria:

  1. Patient must have been admitted to the hospital and spent three overnights. Important note: observation status does not count toward the three night requirement.
    2. Be admitted to a Medicare participating facility within 30 days of hospital discharge.
    3. The condition they are being treated for in the Medicare facility must be the same one they were hospitalized for.

For each benefit period, Medicare will pay for all costs the first 20 days, and an additional 80 days on a co-payment basis. If co-pays are not paid for by Medicare supplement or other private insurance, the cost is $167.50 per day (2018).

A benefit period begins the day the beneficiary is admitted to the hospital as a Medicare patient and ends when he has been out of the hospital or not received Medicare Skilled Nursing care for 60 consecutive days. Hence, if a patient doesn’t receive skilled nursing care for 60 days in a row, a new benefit period begins in which he must meet all the requirements set forth above to qualify for Medicare Skilled Nursing care.

Once the patient qualifies for Medicare Skilled Nursing care and is in treatment, his coverage is not guaranteed for the full 100 days. He must be able and willing to participate in therapies. The skilled care must also be required to help the patient improved or prevent or slow down further deterioration of the patient’s conditions.

When Medicate Skilled Nursing coverage is exhausted, patients often consider Medicaid benefits to pay for long term care. For more information on how to pay for Skilled Nursing coverage and Long Term Care, contact a Cleveland Elder Law Lawyer.