What is skilled nursing facility care?
Skilled nursing care refers to any patient care, treatment, or therapy that can only be performed safely and effectively by licensed nurses. It is post hospital care provided at a skilled nursing facility certified by Medicare. This could be a hospital or independent nursing home.
Care includes, though not limited to, the administration of medication, intravenous (IV) feedings, wound care, and the monitoring of vital signs and medical equipment.
Skilled nursing facility (SNF) care provides specialized therapies as needed for meeting your health goals and/or performing daily activities. The main ones being:
Physical therapy – designed exercises and equipment to help patients regain or improve their physical abilities. Help with walking after a hip or knee replacement is a prime example.
Occupational therapy – providing help to enable patients to participate in the activities of everyday life. Occupational therapy is common when there is a loss of mobility, sight, and other conditions which require adaptation to manage daily activities.
Speech-language pathology services – treatment that helps you strengthen or regain speech, language, and swallowing skills
Dietary and nutritional therapy – counseling and management for maintaining dietary needs. This can include meal planning and follow-ups to ensure proper nutritional levels are being met.
How does SNF care work?
Medicare should cover the skilled nursing facility care you need to improve your condition, maintain your ability to function, or prevent your health from getting worse.
What does that really mean?
The best way to explain it may be with an example – I had a client who suffered a mild stroke. He recovered quite well, except for the functionality of his leg. As he was not able to perform daily activities as before, likely impacting his recovery and future well-being, he required an SNF care for physical therapy. Those services were covered.
The same applies to someone needed speech-language therapy after throat surgery or a stroke.
How do I qualify for skilled nursing facility care?
There are a number of rules regarding qualifying for Medicare qualification. Medicare Part A will only cover care if these qualifications are met AND only for a limited time. This is short-term coverage.
In general, Medicare may cover your skilled nursing facility care if you:
- Were formally admitted as an inpatient to a hospital for at least 3 consecutive days
- Enter a Medicare-certified care facility within 30 days of leaving the hospital
- Receive care for the same condition that you were treated for during your hospital stay.
- Need skilled nursing care 7 days per week or skilled therapy services a minimum of 5 days per week
My experiences as an agent have mainly revolved around injuries requiring rehab or when someone becomes immobile, but has a chance to get back to living a ‘normal’ life.
What will it cost?
While Medicare will cover some of the costs, your out-of-pocket depends on your chosen plan. (This is why choosing the correct plan is critical at open enrollment and should be discussed with a professional prior to choosing one.)
Let’s say you’re not on any secondary insurance, relying on Medicare only. You will be responsible for 20% of the bill, which can add up quickly. Medicare does not have a maximum out-of-pocket.
If you are on a Medigap plan, specifically the F or G plan, your first 100 days in the skilled nursing facility are covered before Medicare stops covering.
If you, like the majority of my clients, are on Advantage Plans:
- The first 20 days are typically covered at no charge.
- From days 21 through 60, you will be responsible for roughly $180 a day.
- Then from day 60 to 100 is covered again.
Again, at day 101, you are on your own for all expenses as Medicare does not cover anything after a 100 days.
The basic math is your out of pocket expenses will be over $7,000. At that point, most Advantage Plans reach maximum out-of-pocket (though with some plans the maximum amount of pocket may be $4000 or $5000).
I’m here to help
Please reach out if you have any questions or concerns about what your plan covers. I work with a number of different carriers and am happy to be a resource and help where I can!