Problem:

Melanie has Original Medicare. She broke her hip in a biking accident and spent three days as a hospital inpatient before being admitted to a skilled nursing facility (SNF). Melanie spent 100 days in the SNF, at which point she was discharged because she ran out of Medicare-covered days in her benefit period.

Three weeks later, she broke her leg in another accident and was admitted as a hospital inpatient for five days. After five days, her doctor told her that she should be transferred to a SNF to receive rehabilitation care.

Question:

Will Medicare cover Melanie’s SNF stay for the second accident after she is discharged from the hospital?

What To Do:

No. Medicare will not cover additional days of SNF care as Melanie has used up all of her 100 Medicare-covered SNF days in her benefit period.

SNF care is covered by Medicare Part A. Medicare covers up to 100 days of care at a SNF during each benefit period (days 1-20 in a benefit period are covered in full by Medicare; days 21-100 are covered with a $176 per day in 2020).

A benefit period is the way that Original Medicare Part A measures a beneficiary’s use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you become an inpatient at a hospital and ends after you do not receive Medicare-covered inpatient care at a hospital or SNF for 60 days in a row.

Melanie was not out of the SNF for 60 days in a row. Therefore, she is still within the same benefit period, even though she went to the hospital for a different injury. Since she has already spent the maximum 100 days that Medicare will cover in a SNF, she will not be covered for more days.

Melanie may be responsible for the full cost of the additional time spent in the SNF after her second injury. If she is receiving medically necessary skilled therapy (physical, occupational or speech therapy), Medicare may continue to cover these services, but it will not pay for Melanie’s room and board at the SNF, which may be expensive.

What if Melanie cannot afford to pay out-of-pocket for her SNF care?

There are some other benefits and programs that may be able to help Melanie pay for additional care or provide alternative services.

  • Medicare Part A or B home health benefit: Melanie may qualify for home health care and may be able to receive this type of treatment at home instead of at a SNF. In order to qualify for the home health benefit, Melanie must:
    • Be homebound, meaning it is extremely difficult for her to leave her home and she needs help doing so
    • Need some form of skilled therapy care, such as physical or speech therapy that must be performed by a skilled professional
    • Meet face-to-face with her doctor to approve a plan of care and confirm her eligibility
    • Receive home health care through a Medicare-certified home health agency

Her home health care will be covered by Part A if she meets these requirements and spent three consecutive days as a hospital inpatient or had a Medicare-covered SNF stay. Melanie was a hospital inpatient for five days, therefore she would qualify for home health care coverage through Part A. There is no prior hospital stay requirement for Part B coverage. Melanie should speak with her doctor to see if she qualifies for these benefits.

  • Long term care insurance: If Melanie has separate long-term care insurance, it may cover her SNF stay after Medicare coverage ends.
  • Medicaid: If Melanie’s income is low, she may be eligible for Medicaid, which may cover the SNF stay. She should contact her local Medicaid office or state’s State Health Insurance Assistance Program (SHIP) for more information about Medicaid eligibility.

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