Understanding the Medicare Skilled Nursing Benefit

April 11th, 2017

Many people need skilled nursing care on a shorter-term basis, typically after an illness or injury has sent them to the hospital, but before they are up to caring for themselves at home. In these cases, Medicare does offer coverage for care in a skilled nursing facility. It's wise to understand what this Medicare skilled nursing benefit covers before you need to put it into action.

The Difference Between Nursing Homes, Rehab, and Skilled Nursing Facilities

It's important to understand the types of facilities for which Medicare offers (and does not offer) coverage. Sometimes, after a hospital stay and before returning home, it's said that a patient is in "rehab." Medicare does offer some coverage for inpatient acute rehabilitation facilities, but this is not the same type of care or coverage; acute rehabilitation typically involves more intensive rehabilitation and therapy services.

The Medicare skilled nursing benefit is more properly referred to as "post-acute" rehabilitation. It is appropriate for people who require high levels of nursing and other medical care following acute care in a hospital after an injury, surgery, or illness. The goal of this skilled nursing care is to restore a patient's ability to function in his or her home environment. As such, it is intended to last for a limited time—only days or weeks.

By contrast, what is usually thought of as "nursing home care" is custodial care in a long term facility. The goal is to care for the patient and keep them safe, but is not typically geared to returning them to higher function. Services may include some physical therapy and medication assistance, but are primarily centered around personal care: help with bathing, dressing, eating, toileting, and so on. Medicare does not cover long-term nursing home care. Most people would be well-advised to consult an elder law attorney to plan for the possibility of long-term care.

Requirements for the Medicare Skilled Nursing Benefit

There are two primary requirements for being able to access the Medicare skilled nursing benefit:

  • A recent hospital stay, and
  • Your doctor confirms the need for you to have skilled nursing or rehabilitative care on a daily basis.

A hospital stay, for purposes of this benefit, means that you were admitted to the hospital for at least three days, not including the day you were discharged. Also, the admission must have been for treatment, not simply for observation. You do not need to be discharged directly from the hospital to the skilled nursing facility, but your admission to the skilled nursing facility must be within 30 days of your discharge from the hospital.

As for the requirement of skilled nursing care, that may include the need for treatment that a professional nurse would provide, such as administering injections, medicines, or other treatments, monitoring your vital signs, or changing dressings on a wound. Qualifying rehabilitative care might include the services of physical, speech, or occupational therapists. The care that qualifies for the Medicare skilled nursing benefit must be related for the condition that caused you to be hospitalized.

What the Medicare Skilled Nursing Benefit Covers

The first twenty days of staying in a skilled nursing facility, such as a freestanding nursing facility or a hospital's extended care wing, are covered 100% by Medicare. If a stay longer than twenty days is needed, there is a copay. After 100 days, Medicare no longer offers coverage for a stay, If, however, you later have another illness or injury that requires a stay in skilled nursing care, the first 100 days of care will be covered under the same terms.

Medicare coverage includes

  • A semiprivate room (or, if medically necessary, a private room)
  • Meals
  • Nursing services
  • Medications, treatments, medical supplies and appliances
  • Rehabilitation services

Medicare does not cover the cost of a television or telephone. It also does not cover the cost a private room or private duty nurses unless these are deemed medically necessary.

Learn more about planning for different types of care: