How Does Medicare Work for Skilled Nursing?

Medicare is federal health insurance for those aged 65 and older. Several components make up this insurance. The portion that covers hospital stays, skilled nursing care and in some situations, home health benefits is Medicare Part A.

If you or your loved one is in need of a stay in a skilled nursing facility to receive rehabilitation therapy, you may have some questions about how Medicare Part A works. Here are some of the questions we hear most often.

Five Frequently Asked Medicare Questions

1. Will Medicare cover 100% of my skilled nursing stay for the first 20 days?

While this can be true, your progress could result in a much shorter length of stay. An individual must be making “significant documented progress” in order for skilled services to be covered.

If your goals are met before 20 days, Medicare will no longer pay for your stay.  If you no longer require skilled services Medicare will end payment coverage. This can happen even if you need assistance with activities of daily living and feel you are unable to return to your prior living arrangement.    

2. Is a skilled nursing stay guaranteed after surgery?

When accessing your coverage it is important to know that there are qualifying factors for its use. To receive coverage for a skilled nursing stay following surgery or hospitalization, an individual must meet certain criteria.

One of the most notable qualifiers for admission is that the individual has had a qualifying hospital stay. This is defined as three midnights in the hospital under admitted status. Observation days do not count. Also, they must have been assessed by a care provider as needing daily skilled services. This can include nursing or therapy.

This must include a physician’s order and a recommendation for skilled services such as those provided by the skilled nursing area of senior living communities like Twin Lakes. Skilled services can include administration of intravenous medications, enteral (tube) nutrition, wound management, therapy services, etc.

If a skilled nursing stay is not deemed necessary by your healthcare provider you may still have options. You may be able to access your Medicare Part B coverage for outpatient rehab.  If you feel you can’t go home you may be able to pay for a convalescent stay in a skilled nursing facility.  

3. I was told that I’d have to be non-weight bearing for 6-8 weeks. Will Medicare cover my stay that long?

Medicare will only cover a stay when an individual continues to require skilled services. Skilled days billed to Medicare is determined by the nursing facility staff. The staff’s interpretation of the Medicare Guidelines guides this. The facility issues a Notice of Medicare Non- Coverage. You are to receive the notice no less than two days prior to the last covered day of services.  If the patient doesn’t agree with the determination they can file an appeal.

Your skilled service could be working with a therapist to learn to use a slide board or how to hop. Medicare will end coverage once you’ve worked on the same goal for a reasonable amount of time. If you are not able to learn the skill your care could be considered custodial care.  Medicare doesn’t pay for custodial care.

If your physician orders therapy within a thirty-day window, Medicare will begin coverage again.  If it is greater than thirty days, Medicare will not cover it.

4. What if I am hospitalized more than once during a calendar year?

Example Situation: I had a broken hip six months ago and used Medicare benefits for rehab following my surgery.  I then had a 5-day hospitalization for a urinary tract infection with sepsis. The doctor and the therapist want me to go to rehab again – will my Medicare benefit cover this?

The Medicare website explains:

“If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.”

In addition, Medicare insurance benefits reset under certain conditions. If the patient has had a 60 day period without being hospitalized or in a skilled nursing facility receiving skilled services since their last use of their Medicare benefits.  A new Medicare stay can begin under the qualifying guidelines.

5. I need help with bathing and dressing. Will Medicare cover it?

Medicare is health care insurance that does not cover long-term care services. Long-term care, also referred to as  “custodial care,” is when a person requires help with the personal care tasks of everyday living. Oftentimes you will see these called ‘activities of daily living.’

Activities of Daily Living

• Eating
• Bathing
• Dressing
• Toileting – Being able to get on and off the toilet and perform personal hygiene
• Transfers – Being able to get in and out of a bed or chair.

While everyone’s health situation is unique, it is always important to understand the range of benefits your insurance provides. We also recommend that you keep those closely involved in your care knowledgable. Keep them as educated as possible about the insurance you have. This Planning Guide can be used to be prepared in the event that you have an unexpected change in your health situation.