Skilled Nursing Facility Care

Medicare Part A covers inpatient medically necessary

Medicare Definition of medically necessary: Services are considered medically necessary when those services are both consistent with a person’s diagnosis or condition and are recognized as the prevailing medical community standards or current practices.
To be medically necessary the service provided must be:

In response to pain or a life-threatening condition.

To treat an injury, illness or infection.

To treat a condition that could result in physical or mental disability.

To care for the mother and child through the maternity period.

To achieve a level of physical or mental function.

skilled nursing care in a facility. Coverage begins only if you have a qualifying hospital stay of three or more consecutive days, if the reason for the care in the facility is related to a diagnosis made during hospitalization, and the person enters the Medicare certified skilled nursing facility within 30 days of discharge from the hospital. Coverage is limited to a maximum of 100 days in one benefit period beginning the day of entry into the facility.

Coverage:

The skilled nursing facility coverage includes, but is not limited to:

Semi-private room.
Meals.
Skilled nursing.
Rehabilitative services.
Other services and supplies.

Part A coverage does not pay for help with everyday activities (custodial care) such as dressing, bathing or using the bathroom.

The first 20 days of coverage are paid in full by Medicare.
The remaining 80 days requires the Medicare enrollee to pay a daily co-payment. Current Medicare cost sharing amounts are found in Appendix C of the EPM.

Example:

Sunny is enrolled in Medicare Part A. She is hospitalized on March 17 after an accident involving a porcupine. Sunny is discharged to an SNF on April 2 where she is expected to remain until July 4.

Action:

Sunny is responsible for the following:

Deductible for March 17 through April 1 (hospitalization).

No cost sharing for April 2 – April 21.

Daily coinsurance rate for April 22 – July 4.

Medicare Part A cost sharing amounts can be found in the EPM Appendix C.