Skilled Nursing Exposures in Medicare

As seniors age, long-term care becomes a more pressing concern. However, the expenses associated with such care can escalate rapidly. While Medicare does cover certain aspects of long-term care, it doesn't encompass all related costs. One of the most significant considerations when evaluated long-term care options is cost.

Medicare Coverage for Skilled Nursing Facilities

Medicare provides coverage for skilled nursing facility (SNF) care in defined benefit periods. A benefit period begins on the day you are admitted as an inpatient to a hospital or skilled nursing facility and ends once you have gone 60 consecutive days without requiring inpatient hospital or SNF care. If you are hospitalized again after this 60-day window, a new benefit period begins.

You can enroll in Medicare Part A when you turn 65 or if you have certain qualifying medical conditions. Part A covers inpatient hospital stays and skilled nursing facility care. For most individuals, Part A is premium free if they or their spouse has worked at least 40 quarters (10 years) and paid Medicare taxes. If you do not qualify for premium-free Part A, the monthly premium in 2025 is either $285.00 or $518.00 depending on your work history.

Medicare Part C (Medicare Advantage) plans, offered by private insurers, include all elements of Original Medicare and typically cover skilled nursing facilities. Many options are available, allowing you to choose a plan that fits your healthcare and financial needs.

Medicare Coverage and Costs by Benefit Period

• Days 1-20: Medicare fully covers the cost of care. You pay nothing.
• Days 21-100: Medicare covers most costs, but you are responsible for a daily copayment. In 2025, this copayment is $209.50 per day.
• Days 101 and beyond: Medicare no longer covers SNF costs. You are responsible for the full expense of care.

It is important to note that certain services and items may not be covered, even within the initial 20 day period.

Reducing Out-of-Pocket Costs

Since Medicare does not cover long-term skilled nursing care, there are several ways to help manage costs.
Medicare Advantage Plans: Some plans provide additional skilled nursing care coverage beyond Original Medicare.
Medigap Policies: If you have Original Medicare (but not Medicare Advantage), a Medigap plan can help with out-of-pocket expenses, including copayments.
Long-Term Care Insurance: Policies may cover extended skilled nursing care.
Other Assistance Programs: Public and private programs may help with SNF costs, including:

• PACE (Program of All-Inclusive Care for the Elderly) - A Medicare/Medicaid program that supports community-based healthcare needs.
• Medicare Savings Programs - State programs that assist with Medicare premiums and expenses.
• Extra Help - A Medicare program that helps lower prescription medication costs.

What Medicare Covers in a Skilled Nursing Facility

During a Medicare-covered stay at a skilled nursing facility, a variety of services are included. A semiprivate room is included (unless a private room is medically necessary), meals and dietary counseling, skilled nursing care, medical supplies, medications, medical social services, transportation for medical services not available at the facility, and rehabilitation services are included in your stay. Additionally, therapies (such as physical, occupational and speech) are included with your stay if they are necessary for your treatment.

What Medicare Does Not Cover

Medicare does not cover long term custodial care, which is non-medical assistance with daily activities like bathing or dressing). Private rooms (unless medically necessary) are also not covered). Additionally, toiletries and in room televisions and telephones are not covered by Medicare. These are all items that would be an out-of-pocket expense.

Maximize Your Medicare Coverage

There are ways to maximize your Medicare coverage. First, plan ahead. If a hospital discharge planner suggests a SNF, ensure it is Medicare-certified. Only care provided in Medicare-certified facilities is covered. If you enter a facility that is not Medicare-certified, you will be responsible for payment.

It is also important to confirm inpatient status and track your stay. Ensure you are officially admitted as an inpatient during hospital stays, not under "observation" status. You need to have been admitted as an inpatient for at least three consecutive days (not counting the day of discharge) before being transferred to the SNF.

Request that your doctor record medical justifications for skilled nursing care to document medical necessity. Your physician must confirm that you require daily skilled nursing or rehabilitation services. Without confirming medical necessity, you will be responsible for the bill.
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It is also important to Explore Home Care Options.  Medicare may cover home-based therapies if you have a caregiver available. Most often, home care is more comfortable setting a SNF, which can sometimes be crowded.

Conclusion
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Medicare covers short-term skilled nursing facility stays under specific conditions, with coverage varying based on the length of stay and available supplemental insurance. However, it does not pay for long-term care. Planning ahead and understanding your Medicare benefits can help ensure you have the appropriate  coverage for your healthcare needs.  Reach out to us and let us help you plan for your future!

To Get Help Now, Call Our Office

​Rob Davies
Prairie Grove Insurance
800-254-5200
​608-839-0275