LONG-TERM CARE

SKILLED NURSING FACILITY CARE Medicare hospital insurance helps pay for inpatient care of a Medicare participating skilled nursing facility following a hospital stay, if your condition requires daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility. A skilled nursing facility is a specially qualified facility which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Most nursing homes in the United States are not skilled nursing facilities, and many skilled nursing facilities are not participating in Medicare. In some facilities only certain portions participate in Medicare. If you are not sure whether a facility or a particular portion of a facility participates in Medicare as a skilled nursing facility, ask someone at the facility. If staff at the facility cannot tell you, ask Social Security to check with the Health Care Financing Administration. Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are met:

• You have been in an acute hospital at least three consecutive days (not counting the day of discharge) before your transfer to a participating skilled nursing facility.

• You are transferred to the skilled nursing facility because you require care for a condition which was treated in the hospital.

• You are admitted to the facility within a short time (generally within 30 days) after you leave the hospital.

• A doctor certifies that you need, and you receive, skilled nursing or skilled rehabilitation services on a daily basis.

• The Medicare intermediary or the facility’s Utilization Review Committee does not disapprove your stay.

All conditions must be met. But it is especially important to remember the requirement that you must need skilled nursing care or skilled rehabilitation on a daily basis. Skilled nursing care means care can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical therapy performed by, or under the supervision of, a professional therapist. The skilled nursing care and skilled rehabilitation services you receive must be based on a doctor’s order.  

NOTE: If you disagree with a decision on the amount Medicare will pay on a claim

or whether services you receive are covered by Medicare, you always have

the right to appeal the decision.