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Medicare Part A provides payment for post-hospital care in skilled nursing facilities (SNFs) 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.
Unfair denials of Medicare coverage for skilled nursing facility care occur with surprising frequency. Because Medicare uses rules and procedures which may improperly restrict coverage, patients are sometimes required to pay for care which should be covered by Medicare.
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.
What to Do when Medicare Denies Coverage for Skilled Nursing Facility 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. Also, review the Center's self-help packet for skilled nursing facility appeals.
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.
If the denial is oral (no written notice), call the Center for Medicare Advocacy for free advice.
If coverage is still denied in Medicare’s determination, APPEAL. Call the Center for Medicare Advocacy for legal help. Download a Self-Help Packet here.
Nursing Home Residents' Rights and the LGBT Community (Office of the Long-Term Care Ombudsman)
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