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When will Medicare cover skilled care?

When will Medicare cover skilled care?

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

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

2. You have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, not including the day you leave the hospital**. You must enter the SNF (Skilled Nursing Facility) within 30 days of leaving the hospital (see 5 below). After you leave the SNF, if you re-enter the same or another SNF within a short period of time (generally 30 days), you may not need another 3-day qualifying hospital stay to get additional SNF benefits (see 5 below). This is also true if you stop getting skilled care while in the SNF and then start getting skilled care again within 30 days.

3. Your doctor has ordered the services you need for SNF skilled care, which require the skills of professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists, and are furnished by, or under the supervision, of these skilled personnel.

4. You must require the skilled care on a daily basis and the services must be ones that, as a practical matter, can only be provided in a SNF on an inpatient basis. If you are in a SNF for skilled rehabilitation services only, your care is considered daily care even if the therapy services are offered just 5 or 6 days a week.

You need these skilled services for a medical condition that

  • was treated during a qualifying 3-day hospital stay, or
  • started while you were getting SNF care for a medical condition that was treated during a qualifying 3-day hospital stay. For example, if you are in the SNF because you had a stroke, and you fall and break your leg, Medicare may cover rehabilitation for your broken leg even if you no longer need rehabilitation for the stroke.

5. The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.

6. You get these skilled services in a SNF that is certified by Medicare.

** Time you are being observed in a hospital before you are admitted doesn't count toward the 3-day qualifying inpatient hospital stay.

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