Reimbursement for skilled care

Will Medicare cover physical therapy treatment received in a skilled nursing care facility? And if so, which ones?

Yes, if physical therapy is deemed necessary for full recovery, Medicare will cover the treatment.

Under certain conditions and for a limited time, Medicare Part A — which handles payments for hospital care — covers physical and occupational therapy as well as speech-language therapy provided in a skilled nursing facility, often referred to as an SNF.

Medicare makes it easy for you to know if your procedure will be covered: just log on to https://www.medicare.gov/coverage/skilled-nursing-facility-care.html  and type in the name of the procedure you are considering.

Medicare-covered services include, but aren't limited to:

  • Semi-private room (a room you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy (if needed to meet your health goal)
  • Speech-language pathology services (if needed to meet your health goal)
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
  • Dietary counseling

Medicare covers swing bed services in certain hospitals and when the hospital or critical access hospital has entered into a "swing-bed" agreement with the Department of Health and Human Services under which the facility can "swing" its beds and provide either acute hospital or Skilled nursing-facility-level care, as needed. When swing beds are used to furnish SNF-level care, the same coverage and cost-sharing rules apply as though the services were furnished in a skilled nursing facility.

If you're in a skilled nursing facility but must be readmitted to the hospital, there's no guarantee that a bed will be available for you at the same facility if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there's a cost to hold the bed for you.

Your Medicare insurance will pay for your care if you meet all of these conditions:

  • You have Part A and have days left in your benefit period;
  • You have a qualifying hospital stay;  
  • Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. (If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.)
  • You get these skilled services in a SNF that's certified by Medicare;
  • You need these skilled services for a medical condition that was either:
    • A hospital-related medical condition, or
    • A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.

Your doctor may want you to under observation to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you're getting observation services in the hospital, you're considered an outpatient — you can't count this time toward the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay.

Let’s say you come to the emergency department and are formally admitted to the hospital under a doctor’s order; you stay for three days and are discharged on the fourth day.  Because you met the 3-day inpatient hospital stay requirement, your stay is covered.

If, on the other hand, you came to the emergency room and spent a day getting observation services before being admitted for two more days, your stay won’t be covered because you were considered an outpatient while getting the emergency and observation services. You only have two days of hospital stay on record, thus are ineligible for compensation. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.

If you stop getting skilled care in the skilled nursing facility, or leave the SNF altogether, yourcoverage may be affected depending on how long your break in skilled nursing care lasts.

  • If the break in your skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new stay doesn’t need to be for the same condition that you were treated for during your previous stay.
  • If the break in your skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

Your doctor or other health care provider may want you to get services more often than Medicare covers. Or they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs.  Don’t be afraid to ask questions! You have the right to understand why your doctor is recommending certain services and whether Medicare will pay for them.

Resource:

https://www.medicare.gov/coverage/skilled-nursing-facility-care.html