The cost of skilled nursing care varies and depends on where you live. The good news is that Medicare Part A and private insurance companies may cover costs for a certain amount of time.
“Fortunately, most people have options they can use to pay for skilled nursing expenses, because this type of care is medically necessary,” says Melissa Evans, Licensed Nursing Home Administrator at Riverside Lifelong Health & Rehabilitation Mathews.
Does Medicare Cover Skilled Nursing?
According to Medicare, people who are covered by Medicare Part A (hospital insurance) have coverage for skilled nursing care on a short-term basis. However, all of these conditions must apply:
- You have Part A and have days left in your benefit period to use.
- You have a qualifying inpatient hospital stay.
- Your doctor has decided that you need daily skilled care. You must get the care from, or under the supervision of, skilled nursing or therapy staff.
- You receive these skilled services in a Medicare-certified skilled nursing facility.
- You need these skilled services for a medical condition that is either:
- A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay (not including the day you leave the hospital), even if it wasn't the reason you were admitted to the hospital.
- A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you're getting skilled nursing care).
Which Services Are Covered by Medicare Part A?
Medicare-covered services in a skilled nursing facility can include the following:
- A semi-private room (a room you share with other patients)
- Meals
- Skilled nursing care
- Physical therapy (if needed to meet health goals)
- Occupational therapy (if needed to meet health goals)
- Speech-language pathology services (if needed to meet health goals)
- Medical social services
- Medications
- Medical supplies and equipment used in the facility
- Ambulance transportation (when other transportation endangers your health) to the nearest supplier of needed services that aren’t available at the SNF
- Dietary counseling
Does Private Insurance Cover Skilled Nursing?
Private health insurance plans vary widely in terms of their coverage and policies for skilled nursing facilities.
Most plans provide some type of coverage for short stays in skilled nursing facilities if the services are necessary following a hospital stay.
Private insurance companies will typically only pay for skilled nursing services for providers that are considered “in-network.” Although some health insurance policies will cover services provided by out-of-network providers, they may not cover all of the costs, and patients are often responsible for paying out-of-pocket costs or copayments.
What Else Should I Know?
If you qualify for Medicare Part A skilled nursing coverage, Medicare covers all costs for the skilled nursing facility stay for the first 20 days. On day 21 of a skilled nursing stay, the patient is then responsible for a co-payment for the remainder of the stay, up to 100 days.
Although a co-payment is necessary for stays extended to 21 or more days, many commercial insurance Medicare Supplemental policies (also known as “Medigap,”) which will usually cover some or all of the co-payment costs.
Medicare and health insurance plan coverage can change. Be sure to talk with a health insurance or Medicare representative before you make a decision that will affect your finances. You’ll want to make sure that your provider can keep it going.
“Patients should check with their health insurance carrier and Medicare representative to determine their eligibility for skilled nursing coverage,” says Melissa.
To learn more about skilled nursing care, visit Riverside Health System Skilled Nursing resources online. For more information on Medicare or health insurance coverage, contact your Medicare representative or private health insurance plan administrator.
