Know Your Nursing Home Rights

Because coverage may be improperly restricted, patients are sometimes required to pay for care which should actually be covered by Medicare.

Contents

  1. Medicare Coverage of SNF Care
  2. How to Know if Medicare Should Cover Your SNF Care
  3. Tips for Denials of Nursing Home Care
  4. Articles & Updates

Medicare Coverage of SNF Care

Medicare Part A provides payment for post-hospital care in skilled nursing facilities for up to 100 days during each spell of illness. A “spell of illness” begins on the first day a patient receives Medicare-covered inpatient hospital or skilled nursing facility care and ends when the patient has spent 60 consecutive days outside the institution, or remains in the institution but does not receive Medicare-coverable care for 60 consecutive days.

If Medicare coverage requirements are met, the patient is entitled to full coverage of the first 20 days of SNF care. From the 21st through the 100th day, Medicare pays for all covered services except for a daily co-insurance amount; which is adjusted annually.

Skilled nursing facility coverage includes the services generally available in a SNF: nursing care provided by registered professional nurses, bed and board, physical therapy, occupational therapy, speech therapy, social services, medications, supplies, equipment, and other services necessary to the health of the patient.

How to Know if Medicare Should Cover Your SNF Care

Medicare should pay for skilled nursing facility care if:
  • The patient was hospitalized 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.
  • 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 personnel 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.
Other Important Points
  • The restoration potential of the patient is not the deciding factor in determining whether skilled services are needed.
  • The management of a plan involving only a variety of “custodial” personal care services is skilled when, in light of the patient’s condition, the aggregate of those services requires the involvement of skilled personnel.
  • The requirement that a patient receive “daily” skilled services will be met if skilled rehabilitation services are provided five days per week. Examples of skilled services:
    • Overall management and evaluation of care plan;
    • Observation and assessment of the patient’s changing condition;
    • Levin tube and gastrostomy feedings;
    • Ongoing assessment of rehabilitation needs and potential;
    • Therapeutic exercises or activities;
    • Gait evaluation and training.

Tips for Denials of Nursing Home Care

  • The doctor is the patient’s most important ally. If it appears that Medicare coverage will be denied, ask the doctor to help demonstrate that the standards described above are met.
  • If the nursing home issues a notice saying Medicare coverage is not available and the patient seems to satisfy the criteria above, exercise the beneficiary’s right to an expedited appeal. Call the 1-800 number on the notice by no later than noon of the calendar day following receipt of the notice.
  • Don’t be satisfied with a Medicare determination unreasonably limiting coverage; appeal for the benefits the patient deserves. It will take some time, but appeals are often successful.
  • See our Coverage & Appeals and Self-Help Materials pages.

Articles & Updates