Top Five Questions have about Skilled Nursing Facility Care (and how Medicare bills you!)

doctor and nurse visiting senior woman at hospital

Top five questions seniors have about Skilled Nursing Facility (SNF) care (like how Medicare bills you!)

You’ve heard about the term SNF, and maybe you thought nursing home, but there’s a lot more to it.

1. What defines SNF?

An easy way to think of SNF is as a specialized type of care that only skilled RNs or therapists can provide to treat, manage, observe, and evaluate a high level of medical care. Most commonly, SNF patients are recovering from an illness, injury, or surgery. Facilities must meet certain requirements to be certified as an SNF, and sometimes hospitals are also SNF facilities.

Most people do not receive SNF care for very long, with an average stay of 28 days. SNF care is only designed to treat a health concern for as long as it requires daily care. For example, if you broke your leg, you would go to an SNF after being released from the hospital. The initial care you receive would be considered SNF because it requires staff members specializing in surgery recovery. After you no longer need specialized follow-up care, you would then receive custodial (everyday) care, if you still needed assistance.

Here’s another example of SNF care: You’re hospitalized for a stroke, after which you receive occupational therapy at an SNF in order to relearn impacted basic daily tasks (eating, writing, etc.). If your doctor decides that the occupational therapy treatment isn’t working and that you instead need assistance with basic daily tasks, you are switched to custodial care, which is not covered by Medicare. Depending on the decision you and your doctor make together, you may next receive custodial care in the same facility, be sent home, or be transferred to a facility specializing in daily custodial care. This is because SNF facilities are not meant for maintenance of a health issue but rather for improvement.

2. Is SNF care the same thing as an assisted living?

No. The important difference between a skilled nursing facility and, say, an assisted living facility, is that you receive specialized services at an SNF. These terms are often interchanged mistakenly, so it is important to check your sources when gathering information. Remember Medicare rarely covers custodial care, which can be thought of as help with basic personal tasks. These other non-SNF facilities offer mostly custodial care. Custodial care facilities may have some medical equipment on the premises and may even have some medically trained staff, but the purpose of the facility is different. If your care is defined more by assistance than treatment, then, by most counts, it won’t count as SNF care. Custodial care may sometimes appear medical but is not considered specialized; custodial care can range from assistance with meals to using eye droppers or help bathing. Medicare doesn’t cover custodial care and thus does not cover assisted living facilities.

3. How do you get SNF care covered by Medicare?

Medicare has a number of requirements for your stay at an SNF to be covered, which are all outlined on medicare.gov. The most important one for seniors is the requirement of a qualifying inpatient hospital stay. This means an inpatient hospital stay of three consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital (see our previous blog post to learn about inpatient status). The second most important point is that you must enter the SNF within 30 days of leaving the hospital. Click here to read the full list of requirements.

4. How does a benefit period play in?

As Medicare.gov puts it, a benefit period is “the way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services.” A benefit period refers to the length of time that Medicare covers your care. As an SNF patient, your benefit period lasts 100 days, which means that on day 101, you will pay out of pocket for your SNF care.

You are also allowed up to 30 days after you leave SNF care to re-enter an SNF if needed, without needing a new qualifying inpatient hospital stay. But if it’s been more than 30 days since you had SNF care, Medicare does have some particular requirements:

  • Longer than 30, but less than 60: Your current benefit period continues, but you are required to have another three-day qualifying hospital stay.
  • Longer than 60: It’s like starting over. You’ll need a new 3-day hospital stay, and you’re eligible for a new 100-day benefit period.

There’s no limit to the number of benefit periods you can use. As long as 60 days have passed, you’re starting fresh. And with every new benefit period, there’s a new deductible.

It is important to note that breaks in SNF care can happen even without moving facilities. If at any time your care transitions from specialized to custodial, that is technically a break in SNF care, in which case the countdown to 30 days begins. We recommend that if you are expecting to need SNF care and you have days left on your benefit period, try to re-enter within 30 days so you can avoid the expense and hassle of another inpatient hospital stay.

5. What will I pay?

If you have a Medicare Supplement, or Medigap Plan, in most cases, you shouldn’t have to pay anything out-of-pocket. Medicare covers your qualifying hospital stay except for the deductible—which your Medigap covers—and 100% of your SNF care for the first 20 days.

Starting on day 21, SNF care Medicare requires a daily copay, currently $167.50. Medigap plans C, D, F, F-high deductible, G, M, and N all cover 100% of the copay until day 100, when your benefit period ends.

Your 100th day in an SNF is the last day of your benefit period, and thus your Medicare coverage. On day 101, you start paying full cost out-of-pocket.

Conclusions?

With SNF care, the high costs can add up quickly without meeting Medicare’s hospital and benefit period requirements, so it’s important to stay informed. When you are discharged from the hospital after your qualifying stay into SNF care, a hospital liaison should coach you through your financial transition with Medicare. If you are in the process of being discharged and you haven’t received that help, you can and should ask for it. If you can, ask a loved one to be with you and ask questions and to help you keep track of your days for both your inpatient hospital and SNF stays.

If you have questions about your coverage or your Medigap plan, we can help provide guidance. Our clients trust us and refer us because of availability and willingness to give help and advice throughout the year, not just when it’s time to renew. Please call us at 800-774-1434 or email with any questions you have while navigating this complex process. Call an agent to help shop around for a Medigap Plan to help cover this cost.