As you get older, you might suffer an ailment requiring time in a skilled nursing facility (SNF). Skilled nursing facilities are any medical facility where doctors, pathologists, physical therapists, and medically trained nurses are all required in order to give you the care you need to get better.

But you have to coordinate with medical providers at a hospital first in order to get the okay from Medicare to stay in one of these facilities — unless you’re willing to pay 100% out-of-pocket, that is. On top of that, your Medicare benefits will only pay for a limited stay in an SNF. This limited window in which you are eligible for benefits is called a “benefit period”.

The good news is that you can be eligible for more than one benefit period per year, but it can still get expensive if you aren’t careful. Below is the rundown on how benefits periods work for skilled nursing facilities.

We’ll explain how you can get the most out of your Medicare benefits, as well as what you need to do to protect yourself from exorbitant out-of-pocket costs.

How Skilled Nursing Facilities Benefit Periods Work

The benefit period for staying in an SNF facility covers the first 100 consecutive days (or less) that you require that specific form of specialized care. During your benefit period, Medicare will pay for most of your costs depending on how long you stay in the facility. But once your benefit period runs out, you’re on your own.

Medicare Coverage for Skilled Nursing Care

First 3 Days

You must get checked into a Medicare-qualified hospital and receive at least 3 days of qualifying medical care before checking into the SNF. You must receive an official medical discharge from your doctor which explicitly states that you need SNF care, and they must discharge you to a Medicare-certified SNF facility in order to file a claim. This is also known as the “3-day rule”

Next 20 Days

For the first 20 days of your benefit period, Medicare will pay for the full cost of SNF care with zero out-of-pocket costs for you

Next 80 Days

After the first 20 days, you’ll have an additional 80 days of subsidized SNF care. Without a Medicare supplement plan, however, you’ll have to pay $194.50 per day out-of-pocket. That’s upwards of $15,560 for the entire benefit period out-of-pocket if you’re relying on Medicare alone for your healthcare coverage. This is also known as the “100-day rule”

After your 100 days are exhausted, you’ll either have to start paying 100% out-of-pocket or get medically discharged from the facility for 60 consecutive days. After that, if necessary, you can start a brand new benefit period by following all the steps described above.

The Types of Care That Skilled Nursing Facilities Provide

SNFs are a unique type of facility that aren’t quite hospitals but help patients with medical needs that can’t be met with outpatient therapy.

You must get approval from a qualified medical professional (like a speech and language pathologist, a licensed practical nurse, or a physical/occupational therapist) who agrees that you require this specific level of care.

Medical Conditions Where Skilled Nursing Facilities Care is Necessary

After a stroke

Depending on how severe the stroke is, you may require around-the-clock care to meet your personal hygiene needs, keeping an eye out for multiple strokes, neurological recovery, physical rehabilitation, or occupational speech therapy, among others.

After a traumatic brain injury (TBI)

If you get into a car accident or fall and hit your head, you may need to be kept under observation for several weeks or months in order to manage the condition. It’s not uncommon for TBIs to require many of the same types of care that help stroke victims recover from their injuries.

After one or more severe skeletal fractures

As you get older, your decreased mobility and bone density put you at risk for severe fractures from slips, trips, and falls. These injuries take longer to heal in older citizens and require more intense physical rehab than most fractures.

Hospice care

There are some provisions in your Part A benefits that will cover SNF hospice care, provided it is a Medicare-certified hospice facility. But you will have to pay for your room and board out-of-pocket.

These are just a few examples of why a Medicare recipient might require SNF care. But without proper care in a skilled nursing facility, these injuries/diseases can be debilitating or even life-threatening.

That’s why you shouldn’t hesitate to take advantage of your Medicare benefits and seek this care if your doctor agrees that you need it.

But if you need extended SNF care, you should try to plan ahead and make sure you have some type of supplemental coverage in order to help with copays and out-of-pocket costs.

Medicare Supplement Insurance for Skilled Nursing Facilities

Remember the tens of thousands of dollars in out-of-pocket costs we mentioned earlier for those that need to spend more than 20 days in a skilled nursing facility? You could virtually eliminate those costs with the right Medicare Supplement plan.

All 10 plans offer to pay for 100% of your Part A Medicare coinsurance and hospital costs for 365 days after your Medicare Part A benefits run out. But beware: that doesn’t necessarily apply to SNF care.

There are special benefits specifically for SNF care which Medigap insurance plans cover. Only Medigap Plans C, D, F, G, K, L, M, and N cover SNF coinsurance costs; Plans A and B do not.

Furthermore, two of those plans — K and L — don’t cover 100% of those costs. Plan K only covers 50% of your coinsurance costs after day 20, while Plan L covers a more generous 75% of the coinsurance costs.

Alternatively, you can find yourself a good Medicare Advantage plan which provides benefits for SNF coinsurance costs after your Medicare Part A benefits run out.

But your cost-share responsibility and the number of days your insurance provider will pay for are something you have to negotiate personally with your insurance agent.

FAQs

Can Medicare kick you out of rehab?

More often than not, it’s the facility’s choice whether or not to expel a patient from their care, not Medicare itself. But if Medicare doesn’t pay a claim, and you don’t have the money yourself, the facility may choose to discharge you.

That’s why it’s so important to have supplemental coverage so that your care doesn’t face interruption by such setbacks.

What is the Rehab 60% Rule?

The rehab 60% rule largely applies to inpatient rehabilitation facilities (IRFs) rather than SNF care. Because IRFs are more intense — and usually more expensive — than SNF care, in order to cut costs, there’s an old rule which stipulates that at least 60% of an IRF’s patients must be getting treatment for at least one of 13 specific conditions.

When the percentage falls under 60%, whoever isn’t getting treatment for one of those 13 conditions faces discharge from the facility.

How long will Medicare pay for rehab in a nursing home?

Certain SNF facilities would discontinue care for those who’ve seen their health improvement “plateau”, even if they still required medical care.

The CMS office clarified in 2014 that this wasn’t an enforceable practice anymore; older facilities haven’t caught up on these changes, they may try to discharge patients for fear of Medicare rejecting claims.

So caregivers and beneficiaries in more rural areas may have to work a little harder at patient advocacy. This is in order to make sure they get the care they deserve.

Getting Supplemental Medicare Coverage That Fits You

It’s not uncommon for Medicare beneficiaries to wonder if they’ll have coverage if they need a skilled nursing facility.

If anything, seeing how Medicare coverage for skilled nursing facilities actually works emphasizes the need for supplemental coverage. This will help you avoid the gaps in your coverage.

To that end, our licensed insurance agents are available to help you with any of the questions you have. They can also pair you with the right supplemental plan for your unique needs. This is free of cost to everyone, so there’s no reason not to contact us.

So give us a call or fill out our online rate form today so we can look for the best rates and plans in your area.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.