Medicare and Medicare Advantage plans cover care in a Skilled Nursing Facility (SNF) for up to 100 days if you continue to meet the care requirements. This big “if’ is often both misunderstood and misinterpreted.
What is Skilled Nursing Facility (SNF) Care Anyway?
SNF Care is health care provided by skilled nurses and therapy staff to treat, manage, observe, and evaluate care. These professionals include: RNs, LPNs, PTs, OTs, speech/language pathologists, and audiologists. Care which can be given by non-professional staff, like a Certified Nursing Assistant (CNA), is not skilled care. Medicare and Medicare Advantage plans only cover certain services that are needed daily. Even if the care requirements are met, the cost of the stay in the SNF is usually not reimbursed until the patient is completely recovered.
Skilled care is meant to improve a patient’s condition and/or establish a program designed to mainstream the current condition, preventing or delaying it from worsening. SNF Care is covered only if the required care is administered daily and cannot be provided on an outpatient basis. Skilled Services must be reasonable and necessary for diagnosis and treatment. Once a patient does not exhibit measurable improvement and hits a plateau, skilled care will end. Once the patient reaches a functional level, SNF Care status will terminate. While Medicare will cover 100 days of SNF care, however those days are available, NOT guaranteed.
Barbara Keim, Admissions Coordinator at Laurel View Village Skilled Nursing Facility in Davidsville, PA provides the following example:
“If a patient has a wound that requires care daily dressing changes by a RN or LPN, they would qualify for SNF Care. Once treatment of the wound stabilizes and therefore reduces from daily dressing changes to 3-4 times a week (or can be administered by a CNA) SNF status will end.”
I personally have experienced the confusion associated with qualifying and remaining under SNF Care. My father was admitted to a SNF after a toe amputation. Daily occupational and physical therapy was necessary for him to gain mobility, and balance and a RN was medically required for daily wound dressings. When the therapists determined my father was not improving – as measured by the time he could stand without assistance – he was deemed to have reached his functional level. In addition, his amputation site was showing a lack of healing improvement so the dressing/maintenance care could be administered by a CNA. While a long way from being well and unable to go home, he had reached his “potential”, and his SNF coverage was terminated.
Termination of SNF Benefits
Both Medicare and HMOs are beginning to estimate outcomes upon admission, giving all involved an estimated SNF care time frame. Fifteen to twenty days after admittance to the SNF, a Care Plan Meeting is held to review and discuss goals, estimated outcomes, and assessments. Once a patient begins to reach their functional level, the assessment of coverage may accelerate, reducing days of coverage.
When care is no longer medically reasonable and necessary, or is considered custodial (ex: wound dressing), a written Notice of Medicare Non-Coverage (NOMNC) or the “48 hour notice” will be issued. HMOs have their own version of the NOMNC, but the 48-hour time period is the same. Once issued, the SNF coverage benefit period will end in 48 hours. At that time insurance coverage ends, and the patient and family are faced with hard decisions often both emotionally and financially, particularly when the patient is not able/well enough to return home.
When my father entered the SNF, I counted out 100 days of coverage on a calendar. Like many, I thought he was eligible for 100 days of benefits. We received our NOMNC only 46 days into his stay.
I’ve learned the 100 days of SNF coverage is a mirage; patients rarely obtain 100 full days of SNF care. When a patient is unable to return “home” or to an independent lifestyle after SNF coverage ends, private pay will be necessary. Transparent communication with the SNF is paramount in understanding the covered benefit period and its likely termination, so as to allow the family to plan for what must come next.