Medicare Part A, also known as Hospital Insurance, covers short-term, skilled services in a Skilled Nursing Facility (SNF) following a qualifying event. An SNF provides a higher level of medical care than a standard nursing home, focusing on rehabilitation and recovery delivered by trained professionals like registered nurses and therapists. Coverage is strictly limited to skilled care, such as intravenous injections, physical therapy, or complex wound care. Medicare does not pay for long-term or custodial care, which involves assistance with daily activities like bathing and dressing. This benefit is designed to be a temporary bridge between a hospital stay and a return home or to a lower level of care.
Establishing Eligibility for Skilled Nursing Care
To qualify for Medicare coverage of an SNF stay, a patient must meet criteria establishing a medical necessity for skilled services. The foundational requirement is the “Qualifying Hospital Stay,” mandating the patient must have been an inpatient in a hospital for at least three consecutive days before SNF admission, not counting the day of discharge. Importantly, services received while under “observation status” do not count toward this three-day minimum.
The patient must be admitted to a Medicare-certified SNF within 30 days of leaving the hospital, and the care must relate to the condition treated during the qualifying hospital stay. A physician must certify that the patient requires daily skilled nursing or rehabilitation services that can only be provided in an institutional setting. These services must be needed to improve the patient’s condition or to maintain it to prevent further decline. If the patient’s condition no longer requires daily skilled care, or if the services become primarily custodial, Medicare coverage will end, even if the maximum allowed days have not been used.
The Maximum Duration and Cost-Sharing Structure
Medicare Part A coverage for SNF care is structured around a “benefit period,” which measures a patient’s use of hospital and SNF services. A benefit period begins the day a patient is admitted as an inpatient to a hospital or SNF. It ends only after the patient has not received inpatient hospital or skilled SNF care for 60 consecutive days. There is no limit to the number of benefit periods an individual can have, but each new period requires meeting the initial eligibility requirements again.
The maximum duration of Medicare-covered SNF care is 100 days within a single benefit period. The financial responsibility for this 100-day period is broken into two segments. For the first 20 days of care within the benefit period, Medicare pays the full approved amount, meaning the patient owes a $0 daily copayment.
Starting on day 21, the financial structure shifts. For days 21 through 100 of the benefit period, Medicare continues to pay for a portion of the services, but the patient is responsible for a daily coinsurance amount. This coinsurance is adjusted annually by the Centers for Medicare & Medicaid Services (CMS).
Once a patient reaches day 101 within the same benefit period, Medicare Part A coverage for SNF services ceases entirely. The patient then becomes responsible for 100% of the cost of their care, including room, board, and all medical services. The 100-day limit is a maximum, and coverage can end sooner if the patient no longer requires daily skilled services or is discharged.
Navigating Care After Medicare Benefits End
When a patient exhausts the 100-day Medicare Part A benefit or no longer needs skilled services, the facility must issue a formal notification, such as the Notice of Medicare Non-Coverage (NOMNC). This notice informs the patient that coverage is ending and outlines the right to appeal the decision. The appeals process can be expedited, allowing the patient to request a review from a Quality Improvement Organization (QIO) to challenge the determination of medical necessity.
If coverage ends and the patient chooses to remain in the SNF, the financial responsibility shifts entirely to them. Options for continued payment include private funds (“self-pay”) or utilizing private long-term care insurance policies. Medicare Supplement Insurance (Medigap) plans may cover the daily coinsurance amounts for days 21-100, but they do not extend the duration of the 100-day maximum benefit.
For individuals with limited income and assets, state-level Medicaid programs may offer assistance for long-term nursing home care, which is distinct from Medicare’s short-term SNF coverage. Transitioning to Medicaid often requires meeting strict financial eligibility requirements and may necessitate moving to a facility that accepts Medicaid. Another option is transitioning to a lower level of care, such as returning home with home health services covered by Medicare Part B, or moving to an assisted living facility.