Medicare Coverage of Skilled Nursing-Facility and Rehabilitation-Facility Care

What It Is

Inpatient care in a skilled nursing facility (SNF) or acute rehabilitation care in an inpatient rehabilitation facility (IRF)

What's Covered

There are two different types of inpatient nursing and rehabilitation care that Medicare Part A covers, each under a different set of rules and limitations.

1. Skilled nursing facility (SNF)

Medicare Part A covers inpatient care in a skilled nursing facility under the following circumstances:

• A patient's stay must begin within 30 days of an inpatient hospital stay of at least three days.

• The patient must need, and have a physician's prescription for, daily skilled nursing care or physical rehabilitation.

• Care must be in a Medicare-certified skilled nursing or rehabilitation facility.

• Coverage lasts only while the patient's condition is improving. Once the patient's condition has stabilized, Medicare Part A will no longer cover inpatient care.

2. Inpatient rehabilitation facility (IRF)

Medicare Part A covers acute rehabilitation care in an inpatient rehabilitation facility under the following circumstances:

• The patient must need, and a physician must prescribe, acute rehabilitation consisting of at least two different types of therapy (such as physical and speech therapy, or physical and occupational therapy).

• The patient must need, and a physician must prescribe, at least three hours per day of rehabilitation therapy.

• The patient must need to receive the care as an inpatient, as prescribed by a physician and justified by the facility on an ongoing basis.

• Care must be in a Medicare-certified inpatient rehabilitation facility.

• Coverage lasts only as long as the patient needs the qualifying level of care.

Note: There's no requirement of a prior hospital stay in order to receive IRF coverage, but without prior hospitalization, Medicare is more likely to question the need for inpatient rehabilitation care (as opposed to receiving the care as an outpatient).

Warning: Medicare *doesn't* cover long-term nursing home residence, or a stay of any length in a nursing facility for custodial care, or any level of care that doesn't meet all of the above-described conditions under one or the other type of covered care.

If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for inpatient care in a nursing or rehabilitation facility, contact the plan directly.

What Medicare Pays

1. Skilled nursing facility (SNF)

For the first 20 days of coverage during any benefit period, Medicare Part A pays the full Medicare-approved amount for the cost of a SNF stay. (A benefit period is the period during which someone is a hospital inpatient, plus the following period in a Medicare-covered skilled nursing or rehabilitation facility. A benefit period begins on the first day in the hospital and continues until the patient has been out of the hospital and any other Medicare-covered nursing or rehabilitation facility for 60 consecutive days.)

For days 21 to 100 of a covered stay in a skilled nursing facility during any one benefit period, Medicare pays the full Medicare-approved amount, except for a daily coinsurance amount of $141.50 per day.

After 100 days in a skilled nursing facility in any one benefit period, Medicare no longer pays any of the cost.

2. Inpatient rehabilitation facility (IRF)

Medicare Part A pays 100 percent of the Medicare-approved amount for a stay in an IRF for as long as Medicare agrees that such inpatient care is medically necessary.

Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

• The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?

• The care must be performed or delivered by a healthcare provider who participates in Medicare.