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What Will My Insurance Cover For A Skilled Nursing Facility Stay?

What Will My Insurance Cover For A Skilled Nursing Facility Stay?

When it comes time to make a major healthcare decision, one of the first questions is what will my health insurance cover?  In this post, we explain some of the basics of insurance coverage for skilled nursing facilities.

Click here to connect with a care expert to find out which skilled nursing facilities near you are part of your insurance network.

Medicare Coverage for Skilled Nursing Facilities

Medicare Part A will pay for up to 100 days of skilled nursing care in a licensed skilled nursing facility as long as the patient had a qualifying 3-day inpatient hospital stay and the skilled services you receive in the nursing home are related to that hospitalization. The actual amount of days that Medicare Part A will cover in a skilled nursing facility is primarily determined by the patient’s attending physician.

If a patient qualifies for Medicare Part A skilled nursing coverage, then Medicare covers all costs for the skilled nursing facility stay for the first 20 days. Starting on day 21 of a skilled nursing stay, the patient is then responsible for a co-payment for the remainder of the stay, up to 100 days.

Although a co-payment is necessary for stays extended to 21 or more days, many commercial insurance Medicare Supplemental policies (also known as “Medigap” policies) will usually cover some or all of the co-payment costs. If a patient does not have such co-payment coverage but qualifies for Medicaid, then Medicaid may pay for the co-payment. If an individual does not have insurance or Medicaid coverage for the co-payment, they will be directly responsible for the co-payment.

Medicare Advantage Plan Coverage for Skilled Nursing Facilities

Patients who are covered under a Medicare Advantage Plan instead of the traditional Medicare plan will have policies and coverage very similar to the Medicare coverage policies described above.

Private, Commercial and Employer Sponsored Insurance Coverage

These plans vary widely in their coverage and policies for skilled nursing facilities. The majority of plans typically provide some sort of coverage for short stays in post-acute care / skilled nursing facilities if the services are necessary following a hospital stay. Private insurance companies will typically only pay for skilled nursing services for providers that are considered “in-network.” Some policies will cover services from providers that are “out-of-network,” but they usually do not cover as much of the cost and can leave patients with additional out-of-pocket costs. That’s why it’s so important for patients to check if a skilled nursing facility is part of their insurance network. This is the first step in determining insurance coverage and costs and should be factored into any search for skilled nursing facilities.

Learn more about insurance networks here.

Remember, health insurance payment options and programs that cover skilled nursing facility services are quite complex and regularly subject to change. A patient’s individual insurance policy determines what post-acute care services are covered and paid for. repisodic encourages all patients to consult with their insurance company or administrator for final determination of what post-acute care or skilled nursing services their policy covers.