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Medicare’s Inpatient Skilled Nursing Facility Benefit

Today’s video discusses Medicare’s inpatient skilled nursing facility (SNF) benefit. Skilled services can also be covered by Medicare when provided when one is homebound or an outpatient. There is a good deal to discuss solely with the inpatient benefit so we’ll focus on that today.

First, a recap of what comprises skilled services. Skilled services are provided by a licensed professional such as a nurse, occupational therapist or speech therapist. Under original Medicare, the skilled nursing facility benefit was available after a hospital stay of three days. That requirement was apparently waived during the pandemic so we would expect that rule to apply again after May 11 when, as far as the government is concerned, we are beyond the public health emergency era. Some Advantage Plans are not structured to observe the three-day-stay rule so, as always, check your benefit if you are enrolled in an Advantage Plan.

For Medicare to cover in a skilled nursing facility, one must be “recovering” and meet criteria for actively participating in skilled services. A common misunderstanding is that Medicare coverage is virtually automatic after a hospital stay but that is not the case. Some patients are well enough to be discharged home, of course. And, if an individual is too elderly to physically participate in therapies or unwilling for whatever reason, Medicare will no longer cover. It is common for families to read that the Medicare SNF benefit is 100 days and assume their family member is covered for 100 days but it is actually UP TO 100 days of coverage. Of course, if an individual recovers quickly and is able to go home, that is a positive development. Unfortunately, the situation becomes problematic when the family believes the individual cannot return home and yet Medicare coverage ends. When that happens, one has a right to appeal but an appeal tends to delay the coverage ending by days not weeks. When Medicare will no longer cover the stay, the patient either pays to remain in the facility, has a long-term care policy that will help with payment, or often begins the process of spending down assets in order to be eligible for Medicaid. We advise you to be in contact with the social worker or other staff working on a discharge plan so that you are not surprised by a notice that Medicare will no longer cover.

When one is eligible for the Medicare benefit, Medicare covers the first 20 days of a stay in a skilled nursing facility at 100%. From day 21 on, there is a copayment of $200/day. If an individual is in original Medicare and has a supplement, the supplements with richer benefits cover this copayment but the lesser benefit/lower cost supplements do not. If you are in a Medicare Advantage Plan, you usually pay a copayment per day up to a limited number of days. As always, we recommend you review your Plan documents to determine what the benefit is.

Should someone meet Medicare criteria for the entire 100 days, then the benefit is exhausted until a new benefit period begins. This works in the same way Medicare’s hospital benefit works. If you exhaust benefits, the benefit does not replenish until you have been either “facility free” for 60 days or paid privately or through a long-term care policy for 60 days. After that, a new hospital admission triggers a new benefit period and an individual meeting criteria would again be eligible for up to 100 SNF days at that point.

Readmissions to a hospital or skilled nursing facility are common and there are many rules specific to those situations. Readmissions to both hospitals and skilled nursing facilities come under scrutiny by the Medicare program because they are costly. From the family’s perspective, however, it is important to know that when a patient is readmitted to the hospital from the skilled nursing facility, Medicare does not pay to hold that skilled nursing facility bed. As a result, there is the potential that a patient readmitted to a hospital is discharged to a different skilled nursing facility after the hospital stay. Bed availability among skilled nursing facilities in the area at the time of discharge determines where a patient will be admitted when Medicare covers.

We understand that most people don’t want to become Medicare experts. In our opinion, however, it is desirable to have a working knowledge of how key benefits work, especially if you or a family member is on Medicare or nearing Medicare eligibility.