Question: My mother is unable to walk without assistance by wheelchair or walker, cannot bathe on her own, has lower body assist, has dementia and fear of falling, and is on diapers, but the facility says she is highly functional. What are her chances of getting into a skilled nursing facility?
Answer: In order for Medicare to cover skilled nursing facility care, you have to meet the following requirements:
- You have to have a qualifying hospital stay. This means an inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. (Remember, the time you are being observed in a hospital before you are admitted doesn’t count toward the 3-day qualifying inpatient hospital stay.) You must enter the skilled nursing facility (SNF) within a short period of time (generally 30 days) of leaving the hospital.In addition:
- You have to have Medicare Part A (Hospital Insurance) and have days left in your benefit period. A benefit period begins on the day you start using hospital or SNF benefits under Part A of Medicare. You can get up to 100 days of SNF coverage in a benefit period. [Note: If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital (Part A)” on the lower left corner of the card. You can also find out if you have Part A if you call your local Social Security office, or call Social Security at 1-800-772-1213.]
- Your doctor has to order the services you need for SNF care, which require the skills of professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists, and are furnished by, or under the supervision of, these skilled personnel.
- You require the skilled care on a daily basis and the services must be ones that, as a practical matter, can only be provided in an SNF on an inpatient basis. If you are in an SNF for skilled rehabilitation services only, your care is considered daily care even if the therapy services are offered just 5 or 6 days a week.
- You need these skilled services for a medical condition that was treated during a qualifying 3-day hospital stay, or started while you were getting SNF care for a medical condition that was treated during a qualifying 3-day hospital stay. For example, if you are in an SNF because you broke your hip and then have a stroke, Medicare may cover rehabilitation services for the stroke, even if you no longer need rehabilitation for your hip.
- The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.
- You get these skilled services in an SNF that is certified by Medicare.