Medicare Skilled Nursing Facility Coverage: What You Need to Know
Medicare covers skilled nursing facility care after a hospital stay -- but the rules are strict and confusing. Here is exactly what qualifies and what it costs.
Medicare Skilled Nursing Facility Coverage: What You Need to Know
Medicare covers skilled nursing facility (SNF) care -- but the rules are strict, and many seniors are surprised to find their stay isn't covered. Understanding the requirements before you need them can save thousands of dollars.
The 3-Day Hospital Stay Requirement
To qualify for Medicare-covered SNF care, you must have a qualifying inpatient hospital stay of at least 3 consecutive days (not counting the day of discharge).
Critical distinction: You must be admitted as an inpatient -- not placed under "observation status." Observation status is outpatient care, even if you sleep in a hospital bed for several nights. It does NOT count toward the 3-day requirement.
This distinction has caught many seniors off guard. If your hospital stay is classified as observation status, you may owe the full cost of SNF care out of pocket.
What to do: When admitted to the hospital, ask whether you are being admitted as an inpatient or placed under observation. If it's observation status, ask your doctor to change it to inpatient admission if medically appropriate.
What Medicare Covers in a SNF
After a qualifying 3-day hospital stay, Medicare Part A covers:
- Days 1-20: 100% covered (no cost to you)
- Days 21-100: You pay $161/day coinsurance (2016); Medicare covers the rest
- Days 101+: Medicare pays nothing; you pay 100%
Coverage includes a semi-private room, meals, skilled nursing care, physical/occupational/speech therapy, medications, and medical supplies.
What "Skilled Care" Means
Medicare only covers SNF care when you need skilled nursing or therapy services -- not just custodial care (help with bathing, dressing, eating).
Skilled care includes:
- IV medications or injections
- Wound care requiring professional nursing
- Physical, occupational, or speech therapy
- Monitoring of complex medical conditions
If you only need help with daily activities and no longer need skilled care, Medicare stops paying -- even if you haven't reached day 100.
How Medigap Covers SNF Costs
The $161/day coinsurance for days 21-100 adds up quickly. Medigap Plan G covers this coinsurance 100%, meaning you pay nothing for days 21-100 in a SNF (after your qualifying hospital stay).
This is one of the most valuable benefits of Medigap for seniors who may need rehabilitation after surgery or a serious illness.
Medicare Advantage and SNF Care
Medicare Advantage plans must cover SNF care at least as generously as Original Medicare. Many MA plans have different cost-sharing structures -- some charge a per-day copay for all SNF days, others have different day-count structures.
Always check your MA plan's SNF coverage before a planned surgery or procedure.
What Happens After Day 100
After 100 days, Medicare pays nothing for SNF care. Options include:
- Medicaid (if you qualify based on income and assets)
- Long-term care insurance
- Private pay
The average cost of a semi-private nursing home room in Florida is approximately $200-$250/day ($73,000-$91,000/year) in 2016.
We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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About the Author
William Gray
Independent Medicare BrokerUS Air Force Veteran · Florida Medicare Specialist
William Gray is an independent Medicare insurance broker based in Daytona Beach and Palm Coast, FL. A US Air Force veteran (A-10 crew chief, Germany), he spent years in corporate insurance before going independent to serve Florida seniors directly. He has helped more than 1,000 clients across Northeast Florida compare Medicare Advantage, Medigap, and Part D plans — always at no cost to the client.