Medicaid and Medicare Skilled Nursing Coverage
What Is Skilled Nursing?Before we take a deep dive into Medicare and Medicaid skilled nursing coverage, it’s important to understand what skilled nursing is. Skilled nursing and skilled nursing facilities (SNFs) provide short-term care from skilled staff with specific expertise to treat patients. The goal of a skilled nursing facility is to help you recover to your best possible level of wellbeing. Why would you need skilled nursing? If you have been hospitalized and are ready to be discharged, your doctor will assess whether you can return home or need additional care or therapy in a skilled nursing facility. You will need to meet Medicare’s skilled nursing care eligibility requirements (we’ll cover this later in the article). While skilled nursing sounds similar to nursing care (and the terms are sometimes used interchangeably), the two are quite different when it comes to Medicare coverage. This is essential to know, as Medicare coverage for skilled nursing facility services varies from coverage for a nursing home stay (even if the facility provides both).
Quick tip: Head over to our nursing home vs. skilled nursing guide for an in-depth look at the important differences in care.
Does Medicare Cover Skilled Nursing?Skilled nursing falls under Original Medicare Part A. Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility and ends when you haven’t received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. There are no limitations on the number of benefit periods. Before you receive Medicare-covered skilled nursing care, you have to have a new three-day qualifying hospital stay each benefit period. Medicare-covered skilled nursing services include the following:
- Semiprivate room
- Skilled nursing care
- Ambulance transportation (when other transportation isn’t safe for your health)
- Physical therapy and occupational therapy
- Speech-language pathology services
- Medical social services
- Medical supplies and equipment (also known as durable medical equipment) used in the facility
- Dietary counseling
From the experts: Whether you’re enrolling in Medicare for the first time or making changes during open enrollment, head over to our guide that covers everything you need to know about Medicare.
Who Is Eligible for Skilled Nursing?Medicare Part A (Hospital Insurance) covers skilled nursing care on a short-term basis if all of these conditions are met:
- You are enrolled in Medicare Part A and have days remaining to use in your benefit period.
- You have a qualifying three-day inpatient hospital stay.
- Your doctor has determined you need daily skilled nursing care.
- Your skilled nursing care is administered in a Medicare-certified SNF.
- A hospital-related medical condition treated during your qualifying hospital stay, even if it wasn’t the reason you were admitted to the hospital.
- A condition that started while you received care in the SNF for a hospital-related medical condition.
Inside tip: Original Medicare is split up into hospital care and medical care. Learn the important details behind why we have Medicare Part A and Part B.
How Much Does Skilled Nursing Cost Through Medicare?Your out-of-pocket costs will depend on the number of days skilled nursing care is required.2
- Days 1-20: $0 for each benefit period
- Days 21-100: $185.50 coinsurance per day of each benefit period
- Days 101 and beyond: All costs
Additional Cost FactorsKeep in close contact with your skilled nursing care team to confirm what is covered, what is not, and any coinsurance payments. It’s essential to follow through with the care your physician has established. If you refuse your daily skilled care or therapy, you could potentially lose your Medicare-eligible skilled nursing coverage.
Did You Know: Skilled nursing coverage falls under Medicare Part A. But what about Medicare Part B? Learn everything you need to know about Medicare Part B’s coverage and costs.
Does Medicaid Cover Skilled Nursing?Medicaid provides health coverage to over 74 million Americans, including eligible low-income adults, seniors, and people with disabilities.3 Although Medicaid is a federal government program, individual states are responsible for decisions on coverage and benefits for Medicaid recipients. Skilled nursing falls under Medicaid’s Nursing Facility Services. Eligible Medicaid recipients have to meet criteria for SNF care in their own state, yet the individual states must also abide by federal law and regulations when setting their skilled nursing care requirements and guidelines. According to federal requirements, Medicaid-covered skilled nursing service must provide the following:4
- Nursing and related services
- Specialized rehabilitative services
- Medically related social services
- Pharmaceutical services
- Dietary services individualized to the needs of each resident
- Room and bed maintenance services
- Routine personal hygiene items and services
- Professionally directed program of activities to meet the interests and needs for the wellbeing of each resident
- Emergency dental services (and routine dental services to the extent covered under the state plan)
From the pros: Our Medicare and Medicaid health insurance guide shares all the essentials of Medicare and Medicaid, their differences, and how to know if you qualify for either (or both).
What if I Can’t Afford Skilled Nursing Coverage?In addition to Medicaid, there are other ways to get help to pay for skilled nursing costs and other costs, including these programs: Medicare Savings Programs Supplemental Security Income (SSI) Medicare Part D Extra Help
Pro Tip: Need clarification on coverage? Contact your State Health Insurance Assistance Program (SHIP) center. This state program provides free local health counseling to Medicare recipients.
Where Can I Find Medicare and Medicaid Skilled Nursing Care Near Me?If you or your loved one are in the hospital and need the services of an SNF, the hospital care team is your first point of contact. They’ll discuss skilled nursing care options and verify the necessary treatment is administered in a nearby Medicare-certified or Medicaid-certified skilled nursing facility.
Quick tip: Medicare enrollees can easily search for Medicare-certified providers and facilities through Medicare’s Find & Compare search tool.
- Medicaid recipients: Contact your State Medicaid Agency.
- Medicare recipients: Call 1-800-MEDICARE (800-633-4227). TTY users call 877-486-2048.