Medicare Coverage for Skilled Nursing Facility Care in CT

What Medicare pays towards your Skilled Nursing Facility stay.

Medicare covers skilled care in a skilled nursing facility (SNF) under certain conditions for a limited time. Skilled care is health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. Examples of skilled care include changing sterile dressings and physical therapy. It is given in a Medicare-certified SNF. Care that can be given by non-professional staff is not considered skilled care. Medicare covers certain skilled care services that are needed daily on a short-term basis (up to 100 days).

Medicare will cover skilled care only if all of the following conditions are met:

1. You have Medicare Part A (Hospital Insurance) and have days left in your benefit period to use.

2. You have a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more, not including the day you leave the hospital. You must enter the SNF within a short time (generally 30 days) of leaving the hospital and require skilled services related to your hospital stay. After you leave the SNF, if you re-enter the same or another SNF within 30 days, you don’t need another three-day qualifying hospital stay to get additional SNF benefits. This is also true if you stop getting skilled care while in the SNF and then start receiving skilled care again within 30 days.

3. Your doctor has decided that you need daily skilled care. It must be given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you are in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week.

4. You get these skilled services in a SNF that has been certified by Medicare.

5. You need these skilled services for a medical condition that:
- Was treated during a qualifying 3-day hospital stay, or
- Started while you were receiving Medicare-covered SNF care. For example, you are in the SNF because you had a stroke, and you develop an infection that requires I.V. antibiotics.

The amount you need to pay.

You pay the amounts below for each benefit period in 2009 following at least a 3-day covered hospital stay:
Days 1 - 20: $0 for each day.
Days 21 - 100: $128 for each day.
Days over 101: You pay 100%.

A benefit period begins the day you enter a hospital or skilled nursing facility. The benefit period ends when you haven’t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

While you are in the Medicare-certified part of the facility, your therapy services (physical therapy, occupational therapy, and speech-language pathology) must be billed by the facility. No other therapy service may be billed by another setting, such as an outpatient hospital. If you leave the Medicare-certified part of the facility, your therapy services in the non-Medicare-certified part of the facility are limited by a specific dollar amount each year unless you get the services from an outpatient hospital.

For more information, you may call 1-800-289-8376