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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)
- Joint Statement on Turmoil in the Nursing Home Industry January 3, 2019
- Elder Justice “No Harm” Newsletter – Issue 10 December 13, 2018
- State Attorneys General Successfully Take on Nursing Home Issues November 29, 2018
- CMS Proposes Rollback of Emergency Preparedness Requirements to Reduce “Burdens” for Nursing Home Providers November 20, 2018
- Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay November 15, 2018
- Center for Medicare Advocacy Comments on Proposed Nursing Home Legislation and Rule November 8, 2018
- HHS Publishes Final Rules Providing Annual Inflation-Related Increases for Civil Money Penalties in Its Programs. Better Late than Never? November 1, 2018
- Checklist for Medicare Nursing Home “Improvement Standard” Denials October 25, 2018
- Who Owns Nursing Facilities and Why? October 4, 2018
- Transfer and Discharge Deficiencies Cited Since 2017: Surveyors Focus On paperwork, Not Residents’ Rights September 20, 2018
- Final Rules for New Medicare Reimbursement System for Skilled Nursing Facilities: Goodbye Therapy August 23, 2018
- Special Focus Nursing Facilities that “Have Not Improved:” Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures August 15, 2018
- Nursing Facilities’ “Quality Measures” Do Not Reflect Actual Quality of Care Provided to Residents August 9, 2018
- Center for Medicare Advocacy Co-Authors Case Study Journal Article on Nurse Staffing Litigation in Arkansas August 2, 2018
- Special Report – Special Focus Facilities: Poor Care for Residents, Limited Consequences for Providers July 30, 2018
- Nursing Home “In-House” Managed Care Plans May Harm Residents July 19, 2018
- Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No June 28, 2018
- Center for Medicare Advocacy Discusses Nursing Home Resident Protections with CMS Administrator Seema Verma June 28, 2018
- CMS Reverses Obama Policy on Nursing Home Quality Enforcement June 21, 2018
- Nursing Home Residents at Risk June 14, 2018
- Read the Center’s Comments on Proposed Reimbursement for Skilled Nursing Facilities June 14, 2018
- Center for Medicare Advocacy Emphasizes Need to Protect Nursing Home Residents at Congressional Briefing June 7, 2018
- Buying and Selling Nursing Homes: Who’s Looking Out for the Residents? May 23, 2018
- Corporate Integrity Agreements and Nursing Homes May 10, 2018
- Nursing Home Roundup April 12, 2018
- Fact Sheet – Skilled Nursing Facility Coverage and Jimmo v. Sebelius April 5, 2018
- Elder Justice Alert: New York Times Publishes Article on Drug Use Among Older Adults March 29, 2018
- Latest Nursing Home Rights Issue Alert February 22, 2018
- Elder Justice Alert: Human Rights Watch Publishes In-Depth Report on Antipsychotic Drug Use in U.S. Nursing Homes February 7, 2018
- Lawsuit Challenging Chronic SNF Understaffing Settled for $72 Million January 24, 2018
- CMS to Propose Revising the Nursing Home Requirements of Participation January 24, 2018
- Medicare Advantage Enrollees Have Fewer SNF Options than Traditional Medicare Beneficiaries January 24, 2018
- CMA Alert -Spotlight on SNF Enforcement December 27, 2017
- CMS Halts Enforcement, as Requested by the Nursing Home Industry December 6, 2017
- CMA Alert – OIG Warns of Abuse in SNFs; Ted Kennedy, Jr. Joins CMA Advisory Board; “Jimmo” Corrective Action Plan August 30, 2017
- CMA Alert – SNF Update: Comments on Reimbursement; Civil Money Penalties Weakened August 9, 2017
- Reversing Obama Rules, Trump Administration Proposes Allowing Nursing Homes to Require Pre-Dispute Arbitration Clauses as a Condition of Admission June 14, 2017
- Issue Brief: Nursing Home Residents in Jeopardy if Medicaid Becomes a Block Grant February 1, 2017
- Nursing Home “Advancing Excellence” Quality Program Ends after a Decade November 16, 2016
- Observation Status Impedes Access to End-of-Life Skilled Nursing Facility Care November 3, 2016
- CMS Rescinds Erroneous Medicare Nursing Home Policy October 26, 2016
- Don’t be Fooled by the Federal Nursing Home Five-Star Quality Rating System October 5, 2016
- New Nursing Home Requirements of Participation: A Missed Opportunity October 5, 2016
- CMS Increases Mandatory Enforcement to Protect Nursing Home Residents August 17, 2016
- A Model to Waive the Three-Day Inpatient Hospital Stay Requirement for Care in a Skilled Nursing Facility July 20, 2016
- Center Comments on Proposed Rules for Medicare Skilled Nursing Facilities June 22, 2016
- International Study: Privatization of Long-Term Care Facilities Does Not Lead to Greater Transparency or More Care March 23, 2016
- “Discharge” from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? January 13, 2016
- Discharge Planning: Tips for Evaluating a Hospital’s Skilled Nursing Facility Placement Choices November 17, 2015
- CMS Proposed Rules for Nursing Facility Requirements of Participation: Center for Medicare Advocacy Submits Comments October 23, 2015
- Proposed Requirements of Participation for Nursing Facilities Do Not Strengthen Standards for Residents July 16, 2015
- Advancing Excellence: Very Few Nursing Homes are “Full Active Participants” and Nearly Half of Them Provide Poor Care June 18, 2015
- CMS Tool for Assessing Civil Money Penalties Imposed Against Nursing Facilities Continues to Ensure that Penalties Will Remain Low January 29, 2015
- Changes to Nursing Home Compare: Some Good, Some Bad November 20, 2014
- Administration Plans Major Improvements to Nursing Home Compare October 16, 2014
- Inpatient Rehabilitation Facilities and Skilled Nursing facilities: Vive La Difference! July 31, 2014
- Quality Assessment and Performance Improvement (QAPI) In Nursing Homes: Diverting CMS Attention from Enforcement June 12, 2014
- Harm from Medicare’s Hospital Observation Status Debated In Congressional Hearing – Center for Medicare Advocacy Presents Beneficiary Perspective May 21, 2014
- Senior Policy Attorney Toby S. Edelman Testifies about Observation Status before Congress May 15, 2014
- Federal Nursing Home Enforcement System is Not Punitive: Setting the Record Straight Again May 8, 2014
- The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again April 17, 2014
- OIG Report: Care in Skilled Nursing Facilities Harmed Nearly One-Third of Medicare Residents in August 2011 March 19, 2014
- Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned March 7, 2014
- CMA Report: Inappropriate Use of Antipsychotic Drugs in Nursing Homes, Part Three – Recommendations to Improve the Citing of Deficiencies January 23, 2014
- CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities December 12, 2013
- Misuse of Antipsychotic Drugs in Nursing Homes: Are We Making Any Progress? November 14, 2013
- $2.2 Billion Johnson & Johnson Settlement Sends New Warning: Antipsychotic Drugs Should Not Be Used to Treat Dementia November 14, 2013
- Debunking Nursing Home Myths about Quality of Care and Enforcement of Federal Care Standards September 12, 2013
- HHS Announces First Guidance Implementing Supreme Court’s Decision on the Defense of Marriage Act August 30, 2013
- CMS Addresses Observation Status Again… And Again, No Help for Beneficiaries May 16, 2013
- Medicare Paid $5.1 Billion to SNFs that Did Not Provide Care-Planning and Discharge-Planning (February 2013 OIG Report) April 18, 2013
- Nursing Home Enforcement by United States Attorneys: What Happened to the Regulatory System? February 7, 2013
- The Worst-Performing Nursing Facilities Are Seldom Sanctioned; Self-Reporting is Not an Accurate Quality Measurement January 24, 2013
- Déjà Vu All Over Again: CMS Decides (Again) Not to Decide About Observation Status November 20, 2012
- How the Ryan Budget (and Republican Platform) Would Hurt Current Nursing Home Residents August 30, 2012
- CMS Invites Public Comment on Observation Status August 9, 2012
- Compare Hospitals or Nursing Homes Using Medicare’s Online Tools July 20, 2012
- More Concerns About Observation Status: Hospitals Join the Chorus July 12, 2012
- Recognizing Elder Abuse Awareness Day: Working Together to Curb Misuse of Powerful Antipsychotic Drugs in Nursing Homes June 14, 2012
- Brown University Confirms Observation Continues to Replace Hospital Admission Status June 7, 2012
- Low Staffing in Nursing Homes Leads to More Deaths May 3, 2012
- Press Release – Fewer Antipsychotic Drugs, More Nurses Will Improve Care in Nursing Homes and Save Money April 19, 2012
- Toby Edelman Statement to Senate Committee Regarding Antipsychotic Drugs in Nursing Facilities April 19, 2012
- Non-Profit vs. For-Profit Nursing Homes: Is there a Difference in Care? March 15, 2012
- Reducing Rehospitalizations… The Right Way March 1, 2012
- Voluntary Nursing Home Improvement Campaign Does Not Work January 11, 2012
- Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys December 22, 2011
- Toby Edelman Testifies Before Senate Special Committee Regarding Antipsychotics In Nursing Homes December 1, 2011
- Preserving Access to Necessary Care: Ending Hospital “Observation Status” November 3, 2011
- Congressman Joe Courtney and Center for Medicare Advocacy Hold Congressional Briefing on Observation Status October 24, 2011
- Medicare Reimbursement For Skilled Nursing Facilities Remains High For 2012 Despite Reductions In Overpayments August 25, 2011
- The Changing Demographics of Nursing Home Care: Greater Minority Access… Good News, Bad News August 18, 2011
- New Initiatives to Improve Services for Dual Eligibles July 15, 2011
- Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities June 30, 2011
- CMA And Others Support Legislation to End “Observation Status” June 21, 2011
- Senators Kerry and Snowe, with Representatives Courtney and Latham, Introduce Legislation to Ensure Skilled Care for Seniors April 26, 2011
- What Happens to Current Nursing Home Residents if the House Budget Resolution Becomes Law? April 21, 2011
- Reducing Antipsychotic Drug Use in Nursing Homes: Save Residents’ Lives, Save Medicare Billions of Dollars March 17, 2011
- More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals March 10, 2011
- Concern over Skilled Nursing Facilities’ Upcoding Medicare Reimbursement Should Not Be Allowed to Deprive Residents of Necessary Care February 10, 2011
- Judge Rejects “Eden Alternative” Defense In Nursing Home Appeal February 3, 2011
- CMS Reins in Overpayments to Skilled Nursing Facilities October 15, 2010
- Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010
- Preventable Emergency Department Visits by Nursing Home Residents August 19, 2010
- Health Reform: The Nursing Home Provisions June 17, 2010
- New GAO Report Demonstrates Need for Stronger Enforcement of Nursing Home Quality Standards: Health Reform Provisions Could Help May 20, 2010
- Off-Label Drug Use Is Common and Hurts Nursing Home Residents March 25, 2010
- Overcoming Barriers to Medicare Coverage of Skilled Nursing Facility Care March 10, 2010
- Observation Services: What Can Beneficiaries and Advocates Do? February 18, 2010
- Nursing Home Residents’ Access to Physicians and Pain Medication February 4, 2010
- Serious Deficiencies in Nursing Facilities are Understated and the Problem May Get Worse January 7, 2010
- Myths About Nursing Home Tort Reforms April 18, 2003
- Important Provisions Reinstated In Medicare Skilled Nursing Facility Regulations September 20, 1999
- The Medicare Prospective Payment System (SNF) September 20, 1999
For older articles, please see our archive.