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Vol. 14, Issue 10 – May 18, 2015

When does Medicare cover skilled nursing facility care?

Dear Marci,

I was recently hospitalized after breaking my hip, and my doctor recommended that I go to a skilled nursing facility for continued therapy treatments. My doctor told me that Medicare will only cover this care in certain circumstances. When does Medicare cover care received in a SNF?

– Alex (Tampa, FL)

Dear Alex,

Medicare may help pay for skilled nursing facility (SNF) care if you meet the following requirements:

  • You need skilled nursing care seven days a week or skilled therapy services at least five days a week. Skilled nursing services include wound care, tube feedings, and IV drug administration. Skilled therapy services include physical, occupational, and speech therapy;
  • You were formally admitted as an inpatient to a hospital for at least three consecutive days. You must enter a Medicare-certified SNF within 30 days of leaving the hospital;
  • You have Medicare Part A before you are discharged from the hospital; and
  • You need care that can only be provided in a SNF.

If you meet these requirements, Medicare should cover the SNF care needed to improve your condition or maintain your ability to function. It is important to note that if you are admitted to the hospital under observation or only receive emergency room services, this time does not count toward meeting the three-day prior hospital requirement for SNF coverage.

When you qualify for a Medicare-covered SNF stay, Medicare covers a semiprivate room, meals, nursing care, therapy services, medical social services, mental health services from clinical social workers, dietary counseling, medications, medical equipment and supplies, and ambulance transportation (when other transportation would be dangerous to your health) to the nearest supplier of needed services that are not available at the SNF.

Original Medicare will pay the full cost of the first 20 days and part of the cost of another 80 days of care in a Medicare-certified SNF each benefit period as long as it is medically necessary. A benefit period is how Original Medicare measures hospital stays. It begins the day you start getting inpatient care and ends when you’ve been out of the hospital or SNF for 60 days in a row. If you have a Medicare Advantage plan, your plan’s coverage of SNF stays may be different. Contact your plan directly to confirm costs and coverage of SNF stays.

In order to find a SNF that meets your needs, you should speak to your doctor and the hospital discharge planner about your SNF care needs. Ask them to find a Medicare-certified SNF in your area that will best meet your needs after you leave the hospital. If you are in a Medicare Advantage plan, you should contact your plan to find out which SNFs are in their network. A network is a group of doctors, hospitals and pharmacies that contract with a managed care plan to provide health care services to plan members.

-Marci

Health Tip
The US Centers for Disease Control and Prevention (CDC) has found that the number of older adults in the US who die from fall-related injuries has nearly doubled since 2000. The report examined information from the National Vital Statistics System between 2000 and 2013. The CDC found that about 30 in every 100,000 older adults died following a fall in the year 2000. By the year 2013, about 57 in every 100,000 older adults died following a fall, nearly a 50 percent increase. Falls are often a triggering event that signal larger health issues, such as balance issues, poor nutrition, or poorly controlled diabetes that results in foot numbness. Researchers have found that the study highlights the importance of coordinated fall-prevention efforts, such as home assessments and balance exercises.

To read more about the study, click here. To read more about fall prevention guidelines, click here.

Need to Know
Medicare Rights University, a comprehensive online training curriculum for professionals, provides a guided learning experience complete with a self-assessment tool, in-depth and user-friendly Medicare content, quizzes to test your knowledge, and downloadable materials.This unique resource provides professionals with a clear path to learning Medicare through a Core Curriculum—four levels of Medicare instruction designed to build on information learned as you progress through each level. Medicare Rights University also offers a Special Topics section which provides an in-depth look at subjects not covered in the Core Curriculum, such as Medicare’s coverage of durable medical equipment and Medicare from a policy perspective.

Check out Medicare Rights University today by going online and visiting www.medicarerightsuniversity.org.

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