AMAC Medicare Advisory Service
Skilled Nursing Care
I am writing on behalf of my mother who recently fractured her hip. After her hospitalization it was recommended that she stay at a skilled nursing facility to help her recover. My question is, will this be covered under Medicare and what will we pay?
-Dave (Orlando, FL)
Skilled nursing care is a covered service under Medicare, but she may have a copay depending on the length of time she requires care and whether she has additional insurance to cover some of the costs.
Let’s examine skilled nursing care in more detail:
Skilled care is nursing and/or therapy that is provided by a trained medical professional. Skilled care may be necessary following a hospital stay to continue healing after an injury, illness or surgery. Some people mistake skilled nursing facilities with a nursing home, although these are two separate things. Skilled nursing facilities provide a temporary residence to those who are recovering, whereas a nursing home is a permanent residence for those who need round-the-clock care. Medicare does not cover custodial care, therefore nursing home care is usually not covered.
Medicare Part A covers skilled nursing care on a short-term basis if you have a qualifying inpatient hospital stay lasting at least 3 days (not including time spent as an outpatient or under observation) and you have time left in your benefit period to use.
A benefit period begins when you have been admitted to a hospital or skilled nursing facility and ends once you have not received care for 60 days in a row. If you enter a hospital or skilled nursing facility after one benefit period has ended, a new one will begin. Keep in mind that each time you start a new benefit period, you will be responsible for the Part A Hospital deductible ($1,556 in 2022), unless you have separate insurance that will pay this for you like a Medicare Supplement plan. If you have a Medicare Advantage plan, be sure to check if a deductible will apply- the amount may vary from the Medicare Part A deductible.
Once she has paid her Part A deductible (if applicable) and is admitted into a skilled nursing facility, she will have a $0 copay for the first 20 days of her stay. From days 21 to 100, she will have a copay of $194.50 per day. If she has insurance that will pay this copay or lower it, then her out-of-pocket costs could be much less. Medicare does not approve more than 100 days in a skilled nursing facility, so if she needs to stay longer than 100 days, she would be responsible for 100% of costs after that point.
While in a skilled nursing facility, your health care provider may recommend services that Medicare will not cover, which may result in out-of-pocket costs for you. Before agreeing to any services, be sure to ask if the services they recommend are covered by Medicare and what your share of the costs will be. Below you will find a brief summary of commonly utilized benefits and services covered by Medicare.
Medicare-covered services in a skilled nursing facility include, but aren’t limited to:
- A semi-private room (a room you share with other patients)
- Skilled nursing care
- Physical therapy (if needed to meet your health goal)
- Occupational therapy (if needed to meet your health goal)
- Speech-language pathology services (if they’re needed to meet your health goal)
- Medical social services
- Medical supplies and equipment used in the facility
- Ambulance transportation (when other transportation endangers your health) to the nearest supplier of needed services that aren’t available at the SNF
- Dietary counseling
Be sure to show all forms of health insurance upon arrival and inform them of any prescriptions you will need to continue taking. If you have any health concerns or dietary restrictions, make sure they are properly noted. Keep copies of all paperwork you receive from the facility. There are certain rights and protections afforded to all residents of skilled nursing facilities, and they are required to provide a written description of these rights to you upon arrival.
Thank you for taking the time to write us Dave. I am sorry to hear about your mother’s injury and I wish her a speedy recovery!
For help with Medicare plans – or any questions you may have about Medicare – contact AMAC’s Medicare Advisory Service at 1-855-611-4856 or request a quote below!