Skilled Nursing Facility (SNF) care can be covered by Medicare if it meets the following criteria:
- The patient was hospitalized as an inpatient (not Observation Status or “outpatient”) for at least three days (not including the day of discharge), and, in most cases, must have been admitted to the SNF within 30 days of hospital discharge.
Note: Medicare Advantage plans often do not require a prior hospital stay to qualify for SNF coverage.
- A physician certifies that the patient needs a Skilled Nursing Facility (SNF) level of care.
- The beneficiary requires and receives “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 personnel such as registered nurses, licensed practical 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.
Note: “Daily” is defined as seven days a week of nursing, or nursing and therapy combined, or five days of just therapy.
- The skilled nursing facility must be a Medicare-certified facility.
Other Important Points:
- The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Skilled services to maintain a patient’s condition or slow deterioration can be covered by Medicare.
- The management of a plan involving only a variety of “custodial” personal care services can be considered skilled when, in light of the patient’s condition, the combination of those services requires the involvement of skilled personnel.
- The requirement that a patient receive “daily” skilled services will be met if skilled therapy services are provided five days per week.
4. A few examples of skilled nursing and therapy services:
a. Overall management and evaluation of care plan;
b. Observation and assessment of the patient’s changing condition;
c. Certain kinds of injections and feedings;
d. Ongoing assessment of rehabilitation needs and potential;
e. Therapeutic exercises or activities;
f. Gait evaluation and training.
5. The individual’s doctor and health care providers are the patient’s most important ally. If it appears that Medicare coverage will be denied, ask the doctor/providers to provide information that the standards described above are met.
6. If the nursing home issues a notice saying Medicare coverage is not available and the patient seems to satisfy the criteria above, ask the nursing home to submit a claim for a formal Medicare coverage determination. The nursing home must submit a claim if the patient or representative requests. The patient is not required to pay for the services until a claim is submitted to Medicare and Medicare officially denies payment.
7. If the nursing home proposes to totally terminate all Medicare covered services or to discharge the patient from the skilled nursing facility, it must issue a written notice offering an “expedited” review of the Medicare denial. (The expedited review is also known as a “fast-track review.) The patient or representative can request the “expedited” review, by following the instructions on the notice provided by the skilled nursing facility.
8. Don’t be satisfied with a Medicare determination inappropriately limiting coverage; appeal for the coverage for which the individual qualifies.