The Myth of 100 Days of Medicare Coverage in a Skilled Nursing Facility - Cona Elder Law

The Myth of 100 Days of Medicare Coverage in a Skilled Nursing Facility

Medicare Part A Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older and individuals under age 65 who have been disabled for at least 24 months who meet the following 5 requirements: 1) the resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) the resident was hospitalized for at least 3 consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) the resident was admitted to the facility within 30 days after leaving the hospital; 4) the resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) a medical professional certifies that the resident requires skilled nursing care on a daily basis.

Where these five criteria are met, Medicare will provide coverage of up to 100 days of care in a skilled nursing facility as follows: the first 20 days are fully paid for, and the next 80 days (days 21 through 100) are paid for by Medicare subject to a daily coinsurance amount for which the resident is responsible. 

But beware:  not everyone receives 100 days of Medicare coverage in a skilled nursing facility. Coverage will end within the 100 days if the resident stops making progress in their rehabilitation (i.e. they “plateau”) and/or if rehabilitation will not help the resident maintain their skill level.  Coverage will also be terminated if the resident refuses to participate in rehabilitation.

Written notice of this cut-off must be provided.  When Medicare coverage is ending because it is no longer medically necessary or the care is considered custodial care, the health care facility must provide written notice on a form called “Notice of Medicare Non-Coverage” to the resident and their designated representative.  If you believe rehabilitation and Medicare coverage is ending too soon, you can request an appeal.  Information on how to request this appeal is included in the Notice of Medicare Non-Coverage.

Don’t be caught off-guard by assuming your loved one will receive the full 100 days of Medicare.  Be sure to have a plan in place to preserve assets while securing government benefits to help pay for long-term health care needs.