What Skilled Nursing Care is Covered by Medicare? And Dealing with Denials

Medicare Part A (Hospital Insurance) will pay up to 100 days of skilled nursing care in a nursing home or at home, if the patient is home-bound and it is physician authorized, or inpatient care in a rehabilitation facility.

Coverage includes meals, skilled nursing care, physical and occupational therapy, speech-language pathology service, medications, medical supplies and equipment, and dietary counseling.

There is no charge for the first 20 days. However, there is a co-pay of $152 per day for the next 80 days, with Medicare covering the remaining expenses.

Sometimes a patient is determined by the facility to not be entitled to the full 100 days of coverage based on Medicare guidelines. However, there has been a change in how facilities are to determine continued eligibility for skilled nursing services that patients and their families should be aware of.

Prior to December 2013, the Medicare Benefit Policy Manual stated that a patient must demonstrate improvement from receiving skilled care services. However, as a result of a class-action law suit, the Medicare Benefit Policy Manual was revised in December 2013 to broaden the criteria for Medicare covered skilled nursing services. The revised manual states that skilled therapy services are covered when the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program or when necessary to maintain the patient’s current condition or prevent or slow further deterioration. Skilled care must also be deemed reasonable and necessary.

Patients and their families need to be vigilant in reviewing Medicare skilled nursing care denials to ensure that the old standard is not being improperly applied. Further, an expedited appeal must commence by noon of the next calendar date of issuance of the notice of denial of benefits. Considering the limited time to make such an appeal, it would be prudent for the patient and his family to consider developing a relationship with an elder law attorney so that when issues arise, an advocate is available to react quickly.