Medicare can be an invaluable resource to seniors, as it
helps contribute to a large variety of benefits and services. Medicare is a
federal health insurance program designed for those aged 65 and over, as well
as those suffering from disabilities. It receives funding via the Supplementary
Medical Insurance Trust Fund and the hospital Insurance Trust Fund.

While its provisions are extremely far reaching and robust,
there are a lot of limitations and, as a result, a lot of misconceptions about
what it does and does not cover, as well as the length of coverage. There are
an especially high number of these misconceptions when it comes to skilled
nursing facilities (SNFs) and long-term care facilities (LTCs).  

One of the biggest misunderstandings of Medicare-based SNF
coverage pertains to how many hours of care a resident receives. Medicare
provides a set number of hours that are to be divided up accordingly throughout
the week to maximize time spent with physical, occupational and speech
therapists. Since daily care is required for Medicare coverage (more on that
later), there can be a lot of down time. For example, 2-3 hours of therapy five
or six days per week, and having the rest of the time to recuperate.

Another common misconception centers around the claim that
Medicare will cover up to 100 days in a SNF. While technically true, there are
a lot of rules and specifics that get overlooked. For example, Medicare covers
the first 20 days at no cost, but beginning on the 21st day and
through the 100th day, the individual must pay a daily coinsurance, which
can reach up to $170.50 per day as of January 1, 2019. This coinsurance can
sometimes take people by surprise despite it being covered in Medicare
literature. Medicare SNF benefits cover 100 days at a time as long as Medicare
SNF criteria (e.g., daily PT/OT required, skilled wound care, IVs, PEG tube,
trach, etc.) is still met. A 60-day break is required to reset benefits. For
example, if you or your loved one were to receive skilled nursing for 30 days,
return home and you/they are not hospitalized for 60 full days, the benefit
period re-sets. However, if you or your loved one returns to the hospital
within those 60 days of leaving skilled nursing, benefits do not re-set and you
will be entering the SNF with 30 days already used.

Additionally, Medicare will only cover SNF care if the following are true:

  • A doctor must order care that requires the help
    of professionals like registered or licensed practical nurses, physical &
    occupational therapists or other similar caregivers
  • You are required to receive skilled care on a
    daily basis (however, if a facility only
    provides care 5 or 6 days a week, Medicare will still acknowledge that as daily
  • There is a detailed plan of care centered around
    progress towards objective and measurable goals. These goals and a prospective
    discharge date must be completed within 72 hours of admission

It is important to keep these factors in mind when planning
or evaluating your or a loved one’s care at a skilled nursing facility.