Elder Law-MEDICARE SKILLED NURSING FACILITY COVERAGE
Medicare Part A covers care in a skilled nursing facility (SNF) for up to 100 days during each spell of illness. If coverage criteria are met, the patient is entitled to full payment for the first 20 days of care. From the 21st through the 100th day, the patient is responsible for a daily co-insurance amount which generally increases each year.
Unfair denials of Medicare coverage for skilled nursing facility care occur with surprising frequency. Because Medicare uses rules and procedures which may improperly restrict coverage, patients are sometimes required to pay for care which should be covered by Medicare.
Medicare should pay for skilled nursing facility care if:
- The patient received inpatient hospital care for at least three days and was admitted to the SNF within 30 days of hospital discharge. (In unusual cases, it can be more than 30 days.)
Important: be certain that the patient was admitted to the hospital by treating physician as an inpatient and not under “observation status.” Observation days in the hospital do not count as inpatient days and will not satisfy Medicare requirements for SNF coverage.
- A physician certifies that the patient needs SNF care.
- The beneficiary requires skilled nursing or skilled rehabilitation services, or both, on a daily basis. Skilled nursing and skilled rehabilitation services are those which require the skills of technical or professional personal such as nurses, physical therapists, and occupational therapists. In order to be deemed skilled, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of. Professional or technical personnel.
- The skilled nursing facility is a Medicare certified facility.
REF: Center for Medicare Advocacy
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