What counts as Medicare-covered skilled nursing facility care?
Medicare Part A covers skilled nursing facility (SNF) care when you need daily skilled nursing or rehabilitation services that can only be provided in a facility. "Skilled" is the key word here—it means care that requires training and judgment from a nurse or therapist.
- Examples of skilled care include:
- Physical therapy after a hip replacement or stroke
- Intravenous (IV) medications or nutritional support
- Complex wound care for surgical sites or pressure ulcers
- Specialized bowel or bladder programs
- Speech therapy after a swallowing difficulty
- Daily nursing assessment and monitoring
Care that is primarily custodial—help with bathing, dressing, eating, or toileting—does not qualify as skilled care, even if you need help with these activities. This distinction matters enormously for your costs. Many families discover mid-stay that the facility is transitioning to custodial care, which Medicare stops covering.
Do you have to spend 3 days in the hospital first?
Yes. To qualify for Medicare-covered SNF care, you must have been admitted to the hospital and stayed there for at least 3 consecutive calendar days. The 3 days must be medically necessary inpatient days—observation days or same-day admission and discharge do not count.
This rule trips up families frequently. Someone might spend 72 hours in the hospital but have some of those hours in observation status rather than inpatient status. Ask the hospital social worker or discharge planner to confirm: "Do I have 3 qualifying inpatient days?" Get it in writing.
Admission to the SNF must also occur within 30 days of hospital discharge (usually within a few days). If you delay, the clock starts running and you may lose coverage.
How long does Medicare Part A SNF coverage last?
Medicare Part A covers up to 100 consecutive days of SNF care, but the benefit is structured in two tiers with different patient costs:
Days 1-20: Medicare pays 100% of covered services. You pay nothing for facility care, room and board.
Days 21-100: You pay a daily coinsurance amount. For 2024, that amount is $200 per day. Medicare pays the rest. This coinsurance increases slightly each year.
Day 101 onward: Medicare pays nothing. You are responsible for the full cost of care.
Many families are surprised that the benefit isn't actually free. Even in days 1-20, you are responsible for any non-covered services or supplies (medications not on the facility's formulary, certain medical equipment, private duty nursing). And the $200/day coinsurance for days 21-100 can add up to $16,000 if you stay the full 100 days.
What is a benefit period and how does it affect your coverage?
A benefit period is a measurement of eligibility for Medicare Part A benefits. It starts when you are admitted to the hospital and ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days.
Once a benefit period ends, a new one begins the next time you are admitted to the hospital for an inpatient stay. You then get another 100 days of SNF coverage in that new benefit period.
However, there is no limit to the number of benefit periods you can have in your lifetime. If you need SNF care again in the future, you could qualify for another 100 days.
The catch: your condition must improve enough to be discharged, or you must have a 60-day gap, to reset. If you stay in the SNF continuously, you are still in the same benefit period and the 100-day limit applies.
What happens when your 100 days of coverage end?
When your 100 days of Medicare-covered SNF care end, your options depend on your financial situation and other insurance:
Private payment: You pay the full daily cost out-of-pocket. This typically ranges from $300–$400 per day for standard rooms and care, higher for areas with expensive housing markets.
Medicaid: If you meet Medicaid financial and medical eligibility requirements (see the Medicaid article), Medicaid can begin covering your care after Medicare ends. This often requires "spending down" assets to the Medicaid limit.
Medicare Advantage: If you have a Medicare Advantage plan (instead of Original Medicare), your SNF benefits may differ. Some plans offer additional days or different coinsurance. Check your plan documents.
Long-term care insurance: If you have a private long-term care insurance policy, it may cover some or all costs after Medicare ends, depending on your policy.
Family payment: You pay with family resources until other coverage kicks in or funds are exhausted.
What is skilled care versus custodial care, and why does it matter?
This distinction is critical because Medicare only pays for skilled care. Custodial care is not covered.
Skilled care: Daily nursing care, therapy, or medical treatment supervised by a registered nurse or licensed therapist. Examples include wound care, IV therapy, therapy sessions, catheter management, medication administration, and health monitoring after acute illness or surgery.
Custodial care: Assistance with activities of daily living (ADL): bathing, dressing, toileting, eating, grooming, transferring in and out of bed. Also included: supervision, reminder to take medications, and general oversight.
Why it matters: A person might need both. They might receive skilled physical therapy (covered) while also needing help with bathing (not covered). Once the therapy ends and they plateau—meaning they stop improving—Medicare often stops paying because the remaining care is custodial.
Families must ask directly: "Is my relative improving enough to justify the skill requirements of the care?" If the therapist says improvement has plateaued and your family member is stable, Medicare will likely deny further payment even if they still need daily assistance.
How can you appeal if Medicare denies SNF coverage?
If Medicare denies payment or says your care is no longer skilled, you have appeal rights. The process has several levels:
Level 1 (Redetermination): You or your family request that Medicare reconsider the denial. You must file within 120 days of receiving the denial notice. Submit any medical evidence showing why care remains skilled and medically necessary.
Level 2 (Reconsideration): If redetermination is denied, you can request a reconsideration by an independent Medicare contractor within 180 days of the redetermination decision.
Level 3 (Administrative Law Judge): If you lose at level 2 and the amount in question is at least $200, you can request a hearing before an administrative law judge.
Important: File your appeal before you move out of the facility if possible. Once you are discharged, it becomes much harder to argue that the care was medically necessary.
Also: You can request "expedited" appeal if you believe immediate discharge would be harmful. This speeds up the process significantly.
What do Medicare Advantage plans cover for SNF care?
If you have a Medicare Advantage plan (Part C), your SNF benefits are governed by that plan, not by Original Medicare rules. Plans vary significantly.
- Some Medicare Advantage plans cover SNF stays the same way Original Medicare does (up to 100 days with the same coinsurance structure). Others offer:
- Additional days beyond 100 (up to 120 or more)
- Reduced coinsurance amounts
- Waived coinsurance for certain conditions
- Coverage for custodial care in limited circumstances
- Before admission, contact your plan to:
- Confirm the SNF is in-network
- Ask how many days are covered
- Ask what your coinsurance or copay amounts are
- Get pre-authorization if required (many plans require it)
- Clarify what happens after coverage ends
Do not assume all Medicare Advantage plans are the same. Some offer much better SNF coverage than Original Medicare, while others offer less.