A Skilled Nursing Facility (SNF) provides medical care administered by, or under the supervision of, licensed health professionals like registered nurses and therapists. This setting is designed for short-term recovery and rehabilitation following an acute illness or injury that required hospitalization. Coverage for this post-hospital care falls under Medicare Part A, the hospital insurance component of the federal program. SNF coverage is temporary and conditional, intended to bridge the gap between an inpatient hospital stay and a return home or transition to a lower level of care.
Eligibility Requirements for Initial Coverage
To cover the initial day of an SNF stay, Medicare Part A requires the beneficiary to meet specific prerequisites related to their preceding medical event. The primary requirement is a “qualifying hospital stay,” meaning the patient must have been formally admitted as an inpatient for three consecutive days. Time spent under “observation status” or in the emergency room before formal admission does not count toward this three-day minimum.
The transfer to the SNF must occur within 30 days of the hospital discharge. The care needed must be for the same condition, or one that arose, during the hospital stay, ensuring the SNF stay is a continuation of treatment. The patient must also require and receive daily “skilled care.” These services are complex and can only be safely and effectively provided by skilled technical personnel.
Skilled services include procedures like intravenous injections, complex wound care, tube feedings, or physical therapy performed five to seven days a week. Coverage is not intended for “custodial care,” which is assistance with daily living activities like bathing, dressing, or eating. If the patient’s condition only requires non-medical help, Medicare Part A will not approve the SNF admission.
The Medicare Benefit Period and Coinsurance Structure
Once a beneficiary meets the initial eligibility criteria, Medicare Part A coverage is measured using a “benefit period.” This period begins the day the patient is admitted as an inpatient to a hospital or SNF. A benefit period ends only when the patient has been out of a hospital or has not received skilled care in an SNF for 60 consecutive days.
A beneficiary is entitled to a maximum of 100 days of covered SNF care within each benefit period. If a patient requires subsequent skilled nursing care after a benefit period ends, a new benefit period begins, resetting the 100-day clock and requiring a new Part A deductible payment. The covered days follow a distinct cost-sharing model.
For the first 20 days of a covered SNF stay, Medicare pays 100% of the allowable charges, resulting in a zero copayment for the beneficiary. The financial responsibility shifts starting on day 21. For days 21 through 100, the beneficiary is responsible for a daily coinsurance payment.
The daily coinsurance amount is established annually by the Centers for Medicare & Medicaid Services (CMS); for example, the rate is set at $209.50 per day for 2025. This cost-sharing continues until day 100. After the 100th day of skilled nursing care within the same benefit period, Medicare Part A coverage ceases entirely, and the beneficiary is responsible for all subsequent costs.
Criteria for Continued Payment and Maintaining Coverage
The maximum allowance of 100 days does not guarantee coverage for that entire duration; coverage is conditional on the continuous need for skilled services. To maintain Medicare payment, the SNF must demonstrate through regular review that the patient continues to require daily skilled nursing or rehabilitation services. These services must be complex enough that they can only be provided in a facility setting. Medical professionals assess this need and document the patient’s progress and ongoing requirements.
Coverage may be terminated before the 100-day limit if the patient’s condition improves and the required services are no longer considered “skilled.” Termination also occurs if the care can be safely provided by non-professional personnel or in a less intensive setting. In such cases, the care is reclassified as custodial, which Medicare Part A does not cover. The facility must notify the patient two days before coverage ends using a Notice of Medicare Non-Coverage (NOMNC).
Medicare policy does not permit the termination of coverage solely because a patient has stopped improving or has reached a “plateau” in their recovery. This policy, clarified by the Jimmo v. Sebelius settlement, establishes a “maintenance standard.” As long as skilled care is necessary to maintain the patient’s current condition or to prevent further functional deterioration, Medicare coverage must continue.
Options When Medicare Coverage is Exhausted
When a beneficiary reaches the 100-day limit or no longer meets the requirement for daily skilled care, financial responsibility transfers away from Medicare Part A. This transition requires patients and families to evaluate alternative payment sources, especially if long-term care or continued custodial assistance is necessary.
Private Pay and Long-Term Care Insurance
One common avenue is “private pay,” which involves using personal savings, retirement funds, or liquidating assets to cover the substantial daily cost of nursing home care. Another option is long-term care insurance policies. These policies are specifically designed to pay for custodial care services not covered by Medicare. They must generally be purchased years in advance and have specific daily benefit limits and elimination periods.
Government Programs (Medicaid and Medicare Advantage)
Medicaid, a joint federal and state program, provides a safety net for individuals with limited income and assets. It is the primary government payer for long-term custodial nursing home care in the United States. Eligibility is subject to strict financial criteria, often requiring applicants to “spend down” their assets to meet state-specific limits. Medicare Advantage plans may also offer different SNF benefits or waivers for the three-day hospital stay, but they do not cover indefinite long-term care.