Medicare & Skilled Nursing Facility Care

Who Should Read This

This publication is essential reading for Medicare beneficiaries who are 65 and older, adults with disabilities who are enrolled in Medicare, and anyone who has recently been hospitalized or is preparing for surgery or a serious medical procedure. It is also highly relevant for adult children and caregivers who help elderly parents navigate Medicare decisions after a hospital stay.

People facing recovery from a hip fracture, stroke, major joint replacement, or other conditions requiring daily skilled nursing care or physical therapy will find this publication especially useful. Anyone confused about what Medicare will and will not pay for in a nursing facility — and for how long — should read it carefully before making any care decisions.

Quick Overview

This publication from the Centers for Medicare & Medicaid Services (CMS) explains how Medicare Part A covers care in a skilled nursing facility (SNF) following a qualifying hospital stay. It outlines eligibility requirements, what services are covered, what costs you can expect to pay, and what rights you have during your SNF stay. The original publication is a brief, four-page beginner-level guide designed to help Medicare beneficiaries understand the basics before or during a SNF admission.

Key Takeaways

• Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period, but only if specific eligibility conditions are met.
• You must have a qualifying inpatient hospital stay of at least 3 consecutive days before Medicare will cover SNF care. The day of discharge does not count toward the 3 days.
• The first 20 days in a SNF are covered at no cost to you. From day 21 through day 100, you pay a daily coinsurance amount.
• After 100 days, Medicare pays nothing. You are responsible for all costs.
• The SNF must be Medicare-certified, and your doctor must order the skilled services you need.
• You have the right to appeal if you believe your Medicare-covered SNF services are ending too soon, including the right to request a fast appeal through an independent reviewer.
• There are several ways to get help covering SNF costs, including Medicaid, Medigap policies, long-term care insurance, and employer or union coverage.

Publication Summary

What Is a Skilled Nursing Facility?

A skilled nursing facility, or SNF, is a Medicare-certified care setting equipped with trained staff and medical equipment to treat, manage, and evaluate your health condition. SNFs can operate as part of a nursing home or as a unit within a hospital. They offer a wide range of services including skilled nursing care, physical therapy, occupational therapy, speech-language pathology, intravenous medications, and medical social services. It is important to understand that a SNF is not the same as a regular nursing home or long-term care facility — the key distinction is that SNFs provide medically necessary, skilled services ordered by a doctor.

Eligibility Requirements

Medicare will only cover your SNF stay if all of the following conditions are met. First, you must have Medicare Part A and have remaining SNF coverage days in your current benefit period. Second, you must have had a qualifying inpatient hospital stay of three or more consecutive days — the admission day counts but the discharge day does not. Third, the SNF you are entering must be certified by Medicare. Fourth, you must begin receiving covered SNF care within a short window of time after your hospital discharge, generally within 30 days. Fifth, a doctor must order the skilled services you need, those services must be medically necessary and required daily, and they must be services that can only be provided in an inpatient SNF setting.

The publication also notes that covered SNF services can be for a condition that was treated during your qualifying hospital stay — even if it was not the main reason for your hospitalization — or for a new condition that developed while you were in the SNF. For example, if you entered a SNF after a hip fracture and then suffered a stroke during your stay, care for both conditions may be covered.

What Medicare Covers in the SNF

Medicare Part A covers a broad range of SNF services. These include a semi-private room, meals, skilled nursing care, physician and medical social services, medications, medical supplies and equipment used in the facility, dietary counseling, and ambulance transportation when other transportation would put your health at risk.

Additionally, Medicare covers physical therapy, occupational therapy, and speech-language pathology services when they are needed to help you meet a defined health goal. A health goal is a specific, measurable outcome your care team expects from treatment — such as being able to walk a set distance or safely climb a flight of stairs.

What You Pay

The cost structure for SNF care under Medicare Part A works on a tiered system based on how many days you spend in the facility during a benefit period. For the first 20 days, you pay nothing out of pocket. From day 21 through day 100, you are responsible for a daily coinsurance amount. Once you reach day 101, Medicare coverage ends entirely, and you are responsible for the full cost of your care.

The publication directs readers to visit Medicare.gov or call 1-800-MEDICARE for the most current cost amounts, since these figures adjust each year. There are several resources available to help cover these costs, including state Medicaid programs, Medigap supplemental insurance policies (some of which cover part or all of the SNF coinsurance), long-term care insurance, and employer or union benefits.

Your Rights as a SNF Patient

Patients receiving Medicare-covered SNF care have important legal rights. These include the right to participate in decisions about your care, the right to privacy and confidentiality, and the right to appeal decisions about when your Medicare-covered SNF services end.

If you believe your SNF is discharging you or ending Medicare-covered services too soon, you can request a fast appeal. In a fast appeal, an independent reviewer evaluates whether your skilled care should continue. This is an important protection that many Medicare beneficiaries are not aware of. More information about the fast appeal process is available at Medicare.gov/claims-appeals/your-right-to-a-fast-appeal.

Finding and Comparing SNFs

The publication points readers to Medicare's Care Compare tool at Medicare.gov/care-compare to search for and evaluate skilled nursing facilities in their area. The tool allows you to review health inspection survey reports, staffing levels, quality measure results, and star ratings for nursing facilities near you. Planning ahead — before a health crisis occurs — can help you identify a facility that best meets your needs and preferences.

Frequently Asked Questions

Does Medicare cover all 100 days in a skilled nursing facility? Medicare covers the full cost only for the first 20 days. From day 21 through day 100, you pay a daily coinsurance. After day 100, Medicare pays nothing and you are responsible for all costs.

What happens if I didn't have a 3-day qualifying hospital stay? Medicare will not cover your SNF care without a qualifying inpatient hospital stay of at least three consecutive days. It is important to note that time spent under "observation status" in a hospital does not count toward the 3-day requirement, even if you slept in a hospital bed. This is a common and costly misunderstanding.

Can Medicare cover SNF care for a condition different from my original hospital diagnosis? Yes. Medicare can cover SNF care for a condition that was treated during your qualifying hospital stay, even if it wasn't the primary reason you were admitted. It can also cover a new condition that arose during your SNF stay while you were being treated for an ongoing condition.

What if I think my SNF is ending my care too soon? You have the right to request a fast appeal before your discharge date. An independent organization will review the decision and determine whether your skilled care should continue. You should not wait until after you have been discharged to request this review.

Can a Medigap policy help pay my SNF costs? Some Medigap supplemental insurance policies do cover part or all of the daily coinsurance for SNF days 21 through 100. Check your specific policy or call your insurance company to find out what your plan covers.

Access the Full Publication

Publication Number: CMS Product No. 11359
Publication Date: May 2024
Length: 4 pages