What is a Skilled Nursing Facility
What is a Skilled Nursing Facility? Will Medicare SNF benefits cover doctor's services?
What Medicare benefits am I entitled to a Skilled Nursing Facility? When will Medicare deny coverage at skilled nursing facilites?
How do I qualify for Medicare SNF coverage? What do I do if I am denied benefits?
How many days of care am I entitled to? If I am denied benefits, can I appeal?
Are there SNF co-insurance charges? How does the appeals process work?
What services are NOT covered by Medicare SNF benefits? Is it worth my time and effort to appeal a denial of skilled nursing facility coverage by Medicare?



What is a Skilled Nursing Facility?
A skilled nursing facility, or "SNF," is a nursing home which provides skilled nursing and/or skilled rehabilitation services to patients who need skilled medical care that cannot be provided in a custodial level nursing home or in the patient's home.


What Medicare benefits am I entitled to at a Skilled
Nursing Facility?
Under Medicare SNF benefits, you are entitled to:

Skilled care provided on a daily basis by, or under the supervision of, a registered professional nurse.

Rehabilitative therapies, such as physical therapy, occupational therapy, and speech therapy, when provided at least five days per week.

Bed and board in connection with skilled nursing services.

Prescribed drugs, laboratory work, supplies, appliances, and equipment.


How do I qualify for Medicare SNF coverage?
In order to qualify:

Admission to the SNF must be for a condition that was treated in the hospital and you must have stayed in the hospital for at least three consecutive days.

The hospitalization must usually have occurred within 30 days of your admission to the SNF.

The SNF must be a Medicare "approved" facility.

Your doctor must order skilled nursing services on a daily basis, or skilled rehabilitative services five days a week.

Care may also be given for any new medical problems that develop after you have been admitted to a SNF.


How many days of care am I entitled to?
You are entitled to 100 days of Medicare SNF coverage per benefit period. A benefit period starts when you enter the SNF and begin receiving skilled nursing or rehabilitative services. The benefit period ends after sixty consecutive days during which you haven't been receiving a Medicare covered level of care, regardless of whether you remain at the facility or are discharged.


Your Rights to Skilled Nursing Facility Benefits


Are there SNF co-insurance Charges?
Medicare pays for all covered services during the first 20 days of your stay at the SNF. In 1995, you will be responsible for a daily co-insurance charge of $89.50, for days 21 through 100. This co-insurance amount changes annually.


What services are NOT covered by Medicare SNF benefits?
Medicare's SNF benefit does not provide coverage for a private room (unless medically necessary), private duty nurses, or convenience items, such as telephones or televisions.


Will Medicare SNF benefits coverage doctor's services?
No. Your doctor's services will be covered by your Medicare Part B medical insurance.


When will Medicare deny coverage at skilled nursing
facilities?
Typical Medicare denials include:

The SNF's assertion that the skilled services were provided on a less than daily basis.

A SNF determination that skilled care is not medically reasonable and necessary, or that the care being given is custodial in nature, rather than skilled.

A SNF determination that the care could have been provided in another setting, such as a custodial care facility, or your home.


What do I do if I am denied benefits?
If the SNF determines that the care isn't covered by Medicare, it will notify you with a written Notice of Non-Coverage (NNC) that provides an explanation of the denial.

If you are denied benefits, you will not have to leave the facility immediately. You will, however, be financially responsible for the remainder of your stay at the SNF, unless you appeal the NNC and are granted Medicare coverage.


If I am denied benefits, can I appeal?
Yes. The NNC must include information regarding your right to request that your claim be submitted for review to the facility's Medicare intermediary.

To begin the appeals process:

Complete the review request document and inform the SNF that you want to appeal the NNC.

Submit any additional information that you believe may help you in obtaining Medicare coverage.


How does the appeals process work?
If you appeal, the intermediary will issue an Initial Determination decision. The SNF cannot bill you for services received until you receive the intermediary decision.

If you are not satisfied with the appeal results:

You may request a Reconsideration of the Initial Determination within 60 days of its receipt. Again, you may submit additional information. You should be sure to keep copies of your request for the Reconsideration.

You may, however, be asked to pay your bill while awaiting further decisions.

If you are not satisfied with the Reconsideration results, and you are liable for more than $100.00:

You may request a hearing before an Administrative Law judge (AIJ) of the Social Security Administration. You must request this hearing within sixty days of receiving the Reconsideration. The Reconsideration will explain how to request the hearing.

It is very helpful to have legal representation at the hearing because laws regarding Medicare coverage are very specific and sometimes confusing. A legal representative will review both the circumstances regarding your admission to the Skilled Nursing Facility and your medical records, to be sure that your SNF stay met the requirements for coverage by Medicare.

If you disagree with the judge's decision:

You may request a review by an Appeals Council. If you are unhappy with the Appeals Council decision, you may appeal to the United States District Court if the amount in question is $1000 or more.


Is it worth my time and effort to appeal a denial of
skilled nursing facility coverage by Medicare?
You should appeal if you have received care that you believe Medicare should have covered. You have nothing to lose; appealing will not jeopardize your Medicare benefits. Contact your local MAP office if you have questions about your Medicare Skilled Nursing Facility benefits.

A self-help brochure published by the
Massachusetts Medicare Advocacy Project (MAP) - July 1995
Reprinted with permission

Home, Charitable Giving, Program Information, Newsletter, Private Attorney Involvement,
Client Education Materials, Other Legal Services/Resources, Current Events/News,
Massachusetts Statewide Plan , E-mail Registry