TIPS ABOUT MEDICARE COVERAGE FOR SKILLED NURSING from Patti Singleton, Admissions Coordinator Medicare insurance coverage for stays in a skilled nursing care center is quite limited with very specific criteria for “skilled status” insurance coverage in a rehab center. The individual must have a three day hospital stay prior to admission into the nursing rehab center. This inpatient hospital stay must include three overnights (or midnights) officially admitted to the hospital. The individual must have a physician’s order that a “skilled nursing facility” admission is necessary. At least two of the following must be ordered by the hospital physician to be “skilled” in a nursing care center: IVs for antibiotics, new feeding tubes, complicated wound care, physical, occupational or speech therapies. If skilled therapies (Physical Therapy, Occupational Therapy or Speech Therapy) are supporting the skilled status, the individual receiving the therapies must be able to participate in therapy at least five days a week and must demonstrate significant progress toward his/her goals. If an individual is admitted to a nursing care center under Medicare “skilled status”, the facility will notify the resident when Medicare criteria are no longer being met. The resident then becomes responsible to pay out of pocket for any additional days for inpatient care. Medicare coverage is limited to a total of 100 days in a skilled nursing rehab center. In any situation, original Medicare pays in full for only 20 days of care in a skilled nursing center. Beginning on the 21st day of a Skilled Nursing stay, there is a substantial co-pay, which the resident is responsible to pay. In 2013 the co-pay is $148.00 per day. If a resident has a Medicare Supplement policy, the policy may pay for a portion of the co-pay costs. Insurance companies/policies vary in the amount they cover for co-pay costs. It is suggested you call the customer service representative of the supplemental insurance to verify co-pay costs. It is important to ask about benefits and co-pays for “Skilled Nursing Inpatient stay” when inquiring about the costs.
