Medicare Criteria & Skilled Nursing Facilities
Disabled and elderly Medicare recipients often are not ready to go home after a hospital stay. Major surgery and illness may leave them frail and unable to function as they did before. Skilled nursing facilities offer these patients an option to help them recuperate. Medicare has particular criteria regarding how and when this benefit is covered.
Definition
A skilled nursing facility is a medical institution, either a nursing home or a hospital, that provides skilled care and skilled therapy. Skilled care refers to particular care that registered nurses and licensed practical nurses are required to perform, such as intravenous injections and sterile dressing. Skilled therapy refers to physical, occupational and speech therapy. Daily living activities, such as eating and bathing, are not considered skilled care. If a patient only needs personal care, then Medicare will not cover a stay in a skilled nursing facility.
Admission Criteria
To qualify for a stay in a skilled nursing facility, the Medicare beneficiary must have been an in-patient in a hospital for at least three days during the 30 days that preceded the skilled nursing facility admission. The beneficiary must have been formally admitted. Those who were admitted under "observation status" or were only in the emergency room are not qualified for the skilled nursing facility benefit. The skilled nursing facility also must be Medicare-certified.
Furthermore, the beneficiary must require skilled nursing therapy at least five days a week or skilled care every day of the week. A doctor must state that the patient requires the care, and he must design a plan of care.
What's Included
In addition to skilled care and therapies, Medicare will cover other things the patient needs while in the skilled nursing facility. Medicare will cover the use of medical social services to help the patient cope if she is having difficulty adjusting to life in the skilled nursing facility or showing signs of depression or another mental illness.
Medicare will also cover in full the medications the patient needs while in the skilled nursing facility, and any medical supplies or equipment that are necessary.
Payment
Original Medicare pays for up to 100 days of a stay in a skilled nursing facility per benefit period. Most people do not use the full 100 days, and the typical stay is more like 28 days. A benefit period starts the day the beneficiary enters the skilled nursing facility, and a new one begins after he has been out of the hospital or the skilled nursing facility for at least 60 days in a row.
Original Medicare pays in full for the first 20 days, and then the beneficiary or his supplemental insurance must pay a daily copay.
Medicare Advantage
Medicare Advantage is the private plan option of Medicare. Those with Medicare Advantage plans may have different costs and restrictions for their skilled nursing facility stays. Under this plan, many skilled nursing facilities do not require the three-day hospital stay, and often more days in the skilled nursing facility are covered. However, the patient must use skilled nursing facilities in the plan's network. Criteria for admission may be different, and she ma need to get prior authorization before admission. The beneficiary should call the plan directly for the most accurate information about her Medicare Advantage plan.
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