While Medicare does not pay for long-term care, it will cover up to 100 days of care in a skilled nursing facility (SNF). There are, however, some fairly stringent and somewhat confusing qualifications patients must meet before Medicare will extend this benefit. Unfortunately, because there is some nuance to the rules, many patients find themselves having to pay for SNF care they assumed would be covered.
To help you navigate the ins and outs of Medicare’s SNF benefit, we put together a quick cheat sheet that explains the basics and a few of the details that are not always so obvious.
The Basic Requirements: Hospital Stays, Observation, and Skilled Care
The basic requirements to qualify for Medicare payment of up to 100 days of SNF appear to be simple to meet:
- The patient’s time at a SNF must be preceded by a hospitalization of at least three days (counted as three midnights)
- The patient must require and be receiving skilled care
There is some important small print that applies, and that can make a big difference in terms of coverage.
First, not all 3-day hospital stays meet the actual requirement. In order to qualify a patient for the SNF benefit, a stay must be classified as an “in patient.” Sometimes, even though a patient remains at the hospital, they are classified as being there for “observation only.” Observation-only hospital stays do not meet the Medicare requirement for SNF coverage.
For this reason, it’s important to ask early on how the hospital stay is classified; and—if the classification is observation only—follow up to change the status to in patient. While the doctor or hospital is not obligated to proactively disclose the classification of a patient’s stay, most hospital personnel should be able to answer the question if asked.
If the classification is for observation only, the patient or an advocate can speak with the treating physician to change the classification. It can sometimes help things along to have the patient’s primary care doctor speak directly with the onsite doctor. If the change is made, the three-day count begins from when the change was made (not from when the stay actually started).
The So-called “Improvement Standard” and Jimmo v. Sebelius
Another common challenge faced by patients seeking Medicare coverage for SNF is something called the “improvement standard.” Under Medicare definitions, skilled care covers a range of services from nursing care to a variety of therapies (physical, speech, occupational, etc.). However, many SNFs still apply a disproven “improvement standard” that limits coverage.
Citing the so-called improvement standard, SNFs sometimes say they have the right to end the level of care (and the corresponding Medicare coverage) if the patient’s progress has plateaued. The application of this standard was found to be illegal in the case of Jimmo v. Sebelius.
Legally, the settlement in this case states that both inpatient and outpatient skilled nursing care, home care, and therapy may be covered under Medicare as long as the treatment is helping a patient maintain their existing status or if the treatment is slowing a decline. In other words, Medicare coverage applies as long as the patient is benefitting from the care, regardless of whether or not it is improving the patient’s status.
What to Do with a Notice of Non-coverage
It is likely that during a patient’s time in SNF, the facility may deliver a “notice of non-coverage” stating that the patient no longer requires skilled care and indicating that Medicare coverage will end (even if the patient has not been in the SNF for the allowed 100 days). This is a standard form that gives the recipient the option to either accept the SNF’s decision, or appeal it.
The best option is to ask for the appeal, even if you are not sure of the situation. An appeal doesn’t cost the patient anything, and payment to the facility will be suspended for the duration of the review process. An appeal is an effective way to ensure that the SNF is not applying the previously mentioned “improvement standard.”
It is important to note that if the patient loses the appeal, they will be responsible for fees accrued over the course of the appeal. For this reason, it’s often best to pay for services even during the appeal (the SNF will reimburse fees if the patient wins the appeal).
The Actual Benefit and How It Applies over Time
The actual value of the Medicare benefit for SNF means that for the first 20 days, patients pay nothing, and for days 21 through 100, patients are responsible for a co-payment (unless they have a Medigap policy, which covers co-payments). In 2020, the co-payment for SNF was $176 per day.
For more information, you can check out Medicare’s comprehensive guide on SNF coverage. You can also find a helpful list of resources on various topics—including SNF coverage—on The Center for Medicare Advocacy’s website.
Reach out to us when you need guidance paying for nursing home or home care – there’s a lot to know.
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