Medicare Skilled Nursing Facility Care vs. Nursing Home Care
Short answer
Medicare can cover short-term skilled nursing facility care when specific Part A requirements are met. Medicare generally does not cover long-term nursing home residence when custodial care is the only care you need.
When Medicare can cover skilled nursing facility care
Under the ordinary Original Medicare rule, Part A can cover skilled nursing facility care after a qualifying inpatient hospital stay of at least three consecutive days, not counting the discharge day. You must need daily skilled care, enter a Medicare-certified skilled nursing facility within the required timeframe, and meet Medicare’s other coverage conditions. Certain approved waivers can alter the three-day requirement.
Why observation status matters
Time spent in a hospital under observation is outpatient time. Observation days generally do not count toward the ordinary three-day inpatient hospital requirement for skilled nursing facility coverage, even if you stay overnight. That is why it is important to know whether the hospital has formally admitted you as an inpatient.
Skilled care vs. custodial care
Skilled care requires services that must be performed or supervised by qualified health professionals, such as skilled nursing or rehabilitation. Custodial care is help with activities such as bathing, dressing, eating, or using the bathroom when skilled medical care is not required. Original Medicare generally does not pay for long-term custodial nursing home care when custodial care is the only need.
What Part A can include during a covered SNF stay
A covered skilled nursing facility stay can include room and meals, skilled nursing, therapy, medical social services, medications, supplies and equipment used in the facility, and other covered services. Coverage is subject to Part A benefit-period and cost-sharing rules.
What to verify before discharge from the hospital
Ask whether you have been admitted as an inpatient or are receiving observation services, whether your inpatient stay meets the qualifying-stay rule, whether the proposed facility is Medicare-certified, and whether your doctor believes you need daily skilled care. If you have Medicare Advantage, also check the plan’s network and prior-authorization rules.