Medicare 101 in Skilled Nursing Facilities
There’s always lots of questions that come up when your family decides it’s time to go to a skilled nursing facility (SNF). You’re not alone with your questions. Many families have very similar questions. One question that comes up a lot is about how to pay for treatment, specifically what will Medicare cover. Here at Vienna, we came up with a few basic points about how Medicare works in SNF’s. What we have compiled are a list of general points. Use this information as a starting point to your coverage understanding, not and ending point. Every person is unique, every situation is unique and coverage may vary. Vienna strongly encourage you to reach out to Medicare to confirm your exact coverage.
What types of Medicare do Skilled Nursing Facilities work with?
For the most part, patients who come into rehab using Medicare are covered under Medicare Part A. In order to be covered by Medicare Part A, a patient must first have three consecutive over-night stays at a hospital before being admitted to skilled nursing facility. So for example if your mom goes to the hospital Tuesday morning, she must stay overnight at the hospital at least until Friday morning before being admitted into a SNF for rehab.
Rehab centers can also accept Medicare Part B. Medicare Part B only covers rehabilitation services. Medicare Part B is often used when someone’s stay is covered through their insurance or through private pay. Medicare Part B can also be used for outpatient therapy. For the purpose of simplicity, we’ll be referring to Medicare Part A for the rest of this post.
What kind of coverage do you get with Medicare Part A?
This is a big question, and at Vienna we always encourage families to call and confirm coverage costs at the beginning of their stay. Generally speaking, Medicare allows up to 100 days as long as they deem the patient can still benefit from their stay. The first 20 days are fully covered through Medicare. That includes therapy, board and care, and the room. After that, on day 21, Medicare only covers a percentage of the cost. The remaining cost is covered through insurance or private pay. We strongly encourage families to contact their insurance companies immediately upon admission to find out what, if any they will owe in copays. Every plan is different.
Who decides when the Medicare coverage ends?
If it is within the 100 days of coverage, the Centers for Medicare and Medicaid Services (CMS) decide when Medicare coverage ends. Not the skilled nursing facility. Rehabilitation therapists, social workers, and nurses submit their patient’s progress and recommendations, but at the end of the day CMS has the final say on whether or not a patient’s therapy and coverage should continue. CMS makes their own assessment on whether or not the patient will continue to benefit and improve from the services they are receiving.
In the instance where a patient is receiving and benefitting from therapy for an extended period of time, Medicare will only help with payment the first 100 days.
What happens if you discharge and something happens?
Your dad seemed fine, everything looked good, but an accident happened and now your family needs help. Despite all of the precautions we take, sometimes life still happens. Medicare coverage varies depending the length of time between care.
You need to readmit within 30 days of discharge
The good news is you do not need another three night stay in a hospital. You will need an order from your primary care physician. Medicare coverage will pick up right where it left off. So if you discharged on day 24 of coverage, you will readmit on day 25 of coverage.
You need to readmit after 31 to 60 days after discharge
To readmit at this point, Medicare does require another three night hospital stay. Once you are admitted after that hospital stay, your Medicare coverage will again pick up right where it left off. So if you discharged on day 45 of coverage, you will readmit on day 46 of coverage.
You need to readmit after 60 days of discharge
The good news is after 60 days, your Medicare coverage starts over. CMS refers to these 60 days as the “60 days of wellness.” As long as you did not need to readmit to a hospital or another SNF, you will start back at the beginning with your 100 days of coverage. To readmit past these 60 days, you will again need three consecutive overnight stays at a hospital before being admitted to any SNF.
And those are the basics! We hope this information helps you gain some general understanding about how Medicare works. Again, every situation is unique. This information was compiled to give you some general information and make future conversations easier to navigate. Your coverage may vary. Confirm your exact coverage by contacting a Medicare representative. Go to www.Medicare.gov or call 1-800-633-4227.