Medicare Coverage


of Skilled Nursing 

Facility Care 

This booklet explains: 

Medicare covered skilled care; 

your rights and protections; and 

where you can get help with 

your questions. 

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Centers for Medicare & Medicaid Services 
Table of Contents 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1


Section 1 - The Basics 

A quick look at Medicare coverage of skilled care . . . . . . . . . . . . . . . . . . . .2


What is skilled care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3


Why would I need skilled nursing or rehabilitation care? . . . . . . . . . . . . . . .4


How do I find a SNF (Skilled Nursing Facility)? . . . . . . . . . . . . . . . . . . . .5-7


Section 2 - Medicare SNF Coverage 

When will Medicare cover skilled care? . . . . . . . . . . . . . . . . . . . . . . . . . . . .8


How long does Medicare cover my SNF care? . . . . . . . . . . . . . . . . . . . .9-12


What does Medicare cover? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13


Section 3 - What You Pay 

What do I pay for SNF care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-15


Ways to get help paying for skilled care and other health care costs . . . . .16


Section 4 - Your Care in a SNF 

What is an assessment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17


What is a care plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18


Section 5 - When Your Medicare Coverage Ends 

How will I know when my Medicare SNF coverage ends? . . . . . . . . . .19-20


It is important to plan ahead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20


What if I think I still need SNF care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21


Section 6 - Your Rights and Protections 

What are my rights in a SNF? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22-23


What can I do about quality of care concerns? . . . . . . . . . . . . . . . . . . . . . .24


What if I think my SNF charges are wrong? . . . . . . . . . . . . . . . . . . . . . . . .24

Table of Contents 

Section 7 - Nursing Home Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . .25-30 

Nursing home inspection results on the Internet . . . . . . . . . . . . . . . . . .31-34 

Section 8 - For More Information 

Free copies of Medicare booklets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 

Local telephone numbers of helpful organizations . . . . . . . . . . . . . . . . .36-39 

Section 9 - Definitions of Important Terms (terms in red) . . . . . . . .40-42 

Index (an alphabetical listing of what is in this booklet) . . . . . . . . . . . . .43 

Important note:	 Before you read this booklet, it is important to know how you 

get your Medicare health care. Most people with Medicare get 

their health care through the Original Medicare Plan (also known 

as fee-for-service). The information in this booklet explains SNF 

coverage in the Original Medicare Plan. 

If you get your health care from a Medicare managed care plan 

(like an HMO) or a Medicare Private Fee-for-Service plan, you 

must get at least the same coverage as the Original Medicare 

plan provides. Look for special notes throughout this booklet 

that explain how your SNF benefits, choice of facility, costs, 

coverage, and/or rights and protections may be different. Read 

your plan materials or check with your plan for specific 

information. 
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Introduction 

If you or someone you care for needs SNF (Skilled Nursing 

Facility) care, read this booklet so you will know: 

• What Medicare covers and what you pay for. 

• How to find and compare skilled nursing facilities. 

• How your care is planned. 

• Your rights and protections. 

• Where you can get help. 

A Skilled Nursing Facility (SNF) could be part of a nursing 

I didn’t know what to facility or hospital. Medicare certifies these facilities if they 

expect when I needed have the staff and equipment to give skilled nursing care 

skilled care. Then the and/or skilled rehabilitation services and other related health 

social worker at the services. 

hospital gave me this 

booklet to read. I’m Skilled care is health care given when you need skilled 

so glad she did.
 nursing or rehabilitation staff to manage, observe, and 

evaluate your care. Examples of skilled care are changing 

sterile dressings and physical therapy. Medicare will only 

cover skilled care when you meet certain conditions (see 

page 8). 

Medicare does not cover custodial care. Custodial 

care is care that helps you with usual daily activities like 

walking, eating, or bathing. It may also include care that 

most people do themselves, like using eye drops, oxygen, 

and taking care of colostomy or bladder catheters. Custodial 

care is often given in a nursing facility. See page 16 for 

ways to get help paying for custodial care. 

Generally, skilled care is available only for a short time after 

a hospitalization. Custodial care may be needed for a much 

longer period of time. 

Medicare Coverage of Skilled Nursing Facility Care 1 
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Section 1 - The Basics 

A Quick Look at Medicare Coverage of Skilled Care


This page gives you a quick look at Medicare covered care in a SNF (Skilled 

Nursing Facility). It helps you find answers to questions you may have if you, or 

someone you care for, needs skilled care. The rest of the booklet gives more detail. 

How do I find a facility that gives skilled care? 

1. Read the list of contacts on page 6. 

2. Call or visit the SNFs you are interest in. 

3. Choose the SNF that best meets your needs. 

When and how long does Medicare cover care in a 

skilled nursing facility? 

•	 Up to 100 days if you continue to meet Medicare’s 

requirements (see page 8). 

How much is covered by the Original Medicare 

Plan (see page 14)? 

Medicare Pays For You Pay For 

For Days Covered Services Covered Services 

1 - 20 Full Cost Nothing 

21 - 100 All but a daily A daily 

copayment* copayment* 

Beyond 100 Nothing Full Cost 

Terms in red *NOTE: The copayment is up to $101.50 per day in the 

are defined on year 2002. It can change each year. If you have a Medigap 

pages 40-42. policy with the Original Medicare Plan, or are in a Medicare 

managed care plan or Private Fee-for-Service plan, your 

costs may be different or you may have additional coverage. 

Where can I get help or more information? 

• For free Medicare booklets, see page 35. 

•	 For telephone numbers of local organizations that can 

help you, see pages 36-39 

2 Medicare Coverage of Skilled Nursing Facility Care 
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Section 1 - The Basics 

What is skilled care? 

Skilled care is health care given when you need skilled 

nursing or rehabilitation staff to manage, observe, and 

evaluate your care. Examples of skilled care include 

changing sterile dressing and physical therapy. It is given 

in a SNF (Skilled Nursing Facility). Care that can be 

given by non-professional staff is not considered skilled 

care. People do not usually stay in a SNF until they are 

completely recovered. Medicare covers certain skilled 

care services that are needed daily on a short-term basis 

(up to 100 days). 

Skilled care requires the involvement of skilled nursing 

or rehabilitative staff in order to be given safely and 

effectively. 

Skilled nursing and rehabilitation staff includes: 

• registered nurses; 

• licensed practical and vocational nurses; 

• physical and occupational therapists; 

• speech-language pathologists; and 

• audiologists. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 3 
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Section 1 - The Basics 

Why would I need skilled nursing or 

rehabilitation care? 

You get skilled nursing care to: 

• help improve your condition; or 

•	 maintain your current condition and prevent it from 

getting worse. 

You get skilled rehabilitation care to: 

•	 help improve your condition within a predetermined 

time period; or 

•	 set up a maintenance program designed to maintain 

your current condition and prevent it from getting 

worse. 

Skilled care helps you get better, function more 

independently, and/or learn to take care of your health 

needs. You and your family will be able to take part in 

setting your health goal (see pages 17-18). 

4 Medicare Coverage of Skilled Nursing Facility Care 
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Section 1 - The Basics 

How do I find a SNF (Skilled Nursing 

Facility)? 

If the hospital you are in has its own SNF, you may be 

admitted (moved) there if a bed is available. If not, you 

may need to find an available bed at a separate facility. 

Deciding where to get skilled care is an important 

decision. 

NOTE: If you are in the Original Medicare Plan, you 

can go to any Medicare-certified SNF if a bed is 

available. 

If you are in a Private Fee-for-Service plan, you can go to 

any Medicare-certified SNF if a bed is available, but you 

must let the plan know you need SNF care before you are 

admitted to the SNF. If you don’t tell your plan before 

you are admitted, you may have to pay more for your 

SNF care. 

If you are in a Medicare managed care plan, you may 

have to get your SNF care from a SNF that belongs to 

your plan. Call your plan to see which SNFs belong to 

your plan. 

However, if certain conditions are met, you may be able 

to get your SNF care from a SNF that does not belong to 

your plan. At your request, your plan may be able to 

arrange your SNF care from: 

• A nursing home or continuing care retirement 

community (that gives SNF care) where you lived 

right before you went to the hospital, or 

• A SNF where your spouse lives when you get out of 

the hospital. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 5 
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Section 1 - The Basics 

If you have enough time, you may want to use these 

steps to help find a SNF: 

1. Find out about the SNF’s in your area (see below). 

2. 	 Call or visit the SNFs you are interested in, or 

have someone call or visit for you (see next page). 

3. 	 Choose the SNF that best meets your needs 

(see next page). 

Step 1 - To find out about the SNFs in your area: 

• Ask the hospital’s discharge planner or social worker 

for a list of local SNFs. They may even help you find 

an available bed. Remember, it may be in the hospital 

or part of a nursing home. 

• Ask your doctor, family, friends, or neighbors if they 

have had personal experience with any of these SNFs. 

• Look at www.medicare.gov on the Internet. Click on 

Nursing Home Compare. You can find a list of all the 

nursing homes in your area and general information 

about every Medicare- and Medicaid-certified nursing 

home in the country. It includes nursing home 

inspection results, the number of nursing staff, and 

resident information. Call the nursing home to find out 

if it provides skilled care. If you do not have a 

computer, your local library or senior center may be 

able to help you. 

• Call your state or local Office on Aging (look in the 

blue pages of your local telephone book). Ask for 

information about the SNFs in your area. 

• Call the Long-term Care Ombudsman for your state 

(see pages 36-39). The Ombudsman program helps 

residents of nursing homes solve problems by acting 

on their behalf. Ombudsman staff visit nursing homes 

and speak with residents throughout the year to make 

sure residents’ rights are protected. They are a very 

good source of general information about nursing 

homes and can work to solve problems with your care, 

Terms in red 

are defined on 

pages 40-42. 

6
 Medicare Coverage of Skilled Nursing Facility Care 
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Section 1 - The Basics 

diet, and financial issues. They are not allowed to 

recommend one nursing home over another, but they 

may be able to help you see the facility’s strengths and 

weaknesses. 

• Call 1-800-MEDICARE (1-800-633-4227, or 

TTY/TDD: 1-877-486-2048 for the hearing and 

speech impaired) and ask for a copy of Your Guide to 

Choosing a Nursing Home. This booklet has valuable 

information about what to think about when choosing 

a nursing home. You can also read or print this from 

www.medicare.gov on the Internet. 

Step 2 - Call or visit the SNFs you are interested in, or 

have someone call or visit for you. 

Call or visit the SNFs you are interested in. If you can’t 

do this yourself, ask a family member or friend to do this 

for you. That way you can have information about SNFs 

before you make your decision about where to get your 

skilled care. If you know you will be going to the 

hospital and may need skilled care after your hospital 

stay, it is best to visit and make your plans ahead of time. 

If you call or visit, we recommend that you ask questions 

about the facility, the quality of life for the residents, the 

quality of care, nutrition and hydration (diet and fluid), 

and safety. Look at the Nursing Home Checklist on 

pages 25-34. It helps you ask important questions so you 

can compare SNFs. 

Step 3 - Choose the SNF that best meets your needs. 

If you find more than one facility with a skilled bed 

available, use all the information you get to compare 

them. Trust your senses. If you don’t like what you see 

on a visit, if the facility does not smell clean, or if you 

aren’t comfortable talking to the staff at the facility, you 

may want to choose another SNF. If you feel that the 

patients are treated well, the facility is clean, and the staff 

is helpful, you may feel better about your decision. Once 

you have made your decision, you can make your 

arrangements with the SNF. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 7

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Section 2 - Medicare SNF Coverage 

* If you are not sure if 

you have Part A, look 

on your red, white, and 

blue Medicare card. It 

will show Hospital 

(Part A) on the lower 

left corner of the card. 

You can also find out 

if you have Part A if 

you call your local 

Social Security office, 

or call Social Security 

at 1-800-772-1213. 

Terms in red 

are defined on 

pages 40-42. 

When will Medicare cover skilled care? 

Medicare will cover skilled care only if all of the following 

are true: 

1. 	 You have Medicare Part A* (Hospital Insurance) and 

have days left in your benefit period (see next page) 

available to use. 

2. 	 You have a qualifying hospital stay. This means an 

inpatient hospital stay of 3 consecutive days or more, not 

including the day you leave the hospital. You must enter 

the SNF within 30 days of leaving the hospital. After 

you leave the SNF, if you re-enter the same or another 

SNF within 30 days, you don’t need another 3-day 

qualifying hospital stay to get additional SNF benefits. 

This is also true if you stop getting skilled care while in 

the SNF and then start getting skilled care again within 

30 days. 

3. 	 Your doctor has decided that you need daily skilled care. 

It must be given by, or under the direct supervision of, 

skilled nursing or rehabilitation staff. If you are in the 

SNF for skilled rehabilitation services only, your care is 

considered daily care even if these therapy services are 

offered just 5 or 6 days a week. 

4. 	 You get these skilled services in a SNF that has been 

certified by Medicare. 

5. 	 You need these skilled services for a medical condition 

that: 

• Was treated during a qualifying 3-day hospital stay, or 

•	 Started while you were getting Medicare-covered 

SNF care. For example, if you are in the SNF because 

you had a stroke, and you fall and sprain your wrist. 

8 Medicare Coverage of Skilled Nursing Facility Care 
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Section 2 - Medicare SNF Coverage 

How long does Medicare cover my SNF 

care? 

Medicare uses a period of time called a benefit period to 

keep track of how many days of SNF benefits you use, 

and how many are still available. A benefit period begins 

on the day you start using hospital or SNF benefits under 

Part A of Medicare. You can get up to 100 days of SNF 

benefits in a benefit period. Once you use those 100 

days, your current benefit period must end before you 

can renew your SNF benefits. 

Your benefit period ends: 

• When you have not been in a SNF or a hospital for at 

least 60 days in a row; OR 

• If you remain in a SNF, when you have not received 

skilled care there for at least 60 days in a row. 

There is no limit to the number of benefit periods you can 

have. Once a benefit period ends, though, you must have 

another 3-day qualifying hospital stay and meet the 

Medicare requirements as listed on page 8 before you can 

get another 100 days of SNF benefits. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 9 
Section 2 - Medicare SNF Coverage 

What if I stop getting skilled care in the 

SNF, or leave the SNF altogether? How 

does this affect Medicare SNF coverage if 

I need more skilled care in a SNF later on? 

This depends on how long your break in SNF care lasts. 

If your break in SNF care lasts for: 

Less 

than 30 

days 

• You do not need a new 3-day hospital stay 

to qualify for coverage of additional SNF 

care (see item 2 on page 8). 

• Since your break in SNF care lasted for less 

than 60 days in a row, your current benefit 

period would continue. 

maximum coverage available would be the 

number of unused SNF benefit days 

remaining in your current benefit period. 

At least 

30 but 

less 

than 60 

days 

• Medicare will not cover additional SNF 

care unless you have a new 3-day hospital 

stay. 

the same condition that you were treated for 

during your previous stay. 

• Since your break in SNF care lasted for less 

than 60 days in a row, your current benefit 

period would continue. 

maximum coverage available would be the 

number of unused SNF benefit days 

remaining in your current benefit period. 

At least 

60 days 

• Medicare will not cover additional SNF 

care unless you have a new 3-day hospital 

stay. 

the same condition that you were treated for 

during your previous stay. 

• Since your break in skilled care lasted for at 

least 60 days in a row, this would end your 

current benefit period and renew your SNF 

benefits. 

coverage available would be 100 days of 

SNF benefits. 

This means that the 

The new hospital stay need not be for 

This means that the 

The new hospital stay need not be for 

This means that the maximum 

Terms in red 

are defined on 

pages 40-43. 

10	 Medicare Coverage of Skilled Nursing Facility Care 
Section 2 - Medicare SNF Coverage 

Examples of Medicare Coverage 

In the following examples (1 - 3), assume the patients 

met all the qualifications for Medicare coverage of SNF 

care listed on page 8, including the 3-day qualifying 

hospital stay. They are admitted to a SNF because they 

need skilled care, and are then discharged before their 

benefit period ends. 

Example 1 - Out of the SNF for less than 

30 days 

Mrs. Perkins received 10 days of Medicare-covered SNF 

care when she broke her leg. Her Medicare coverage 

ended when she stopped needing skilled care. She chose 

to go home rather than pay for custodial care. After 10 

days, her doctor decided she needed more skilled care for 

her broken leg and she was readmitted to the SNF. 

Medicare will cover this SNF stay. She has 90 days of 

coverage left in her benefit period. 

Example 2 - Out of the SNF for at least 30 

but less than 60 days 

Mr. Jones received 20 days of Medicare-covered SNF 

care when he had a stroke. His Medicare coverage ended 

when he stopped needing skilled care. He chose to stay 

in the SNF and pay for 2 days of custodial care. He then 

went home. After 34 days, his doctor readmitted him to 

the hospital for 4 more days because of his stroke. He 

was then admitted to a SNF because he needed skilled 

care. Even though Mr. Jones was out of the SNF for 

more than 30 days, since he then had a new qualifying 

hospital stay, Medicare will cover this SNF stay. He has 

80 days of coverage left in this benefit period. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 11 
Section 2 - Medicare SNF Coverage 

Example 3 - Out of the SNF for at least 60 

days 

Mrs. Smith received 20 days of Medicare-covered SNF 

care when she had back surgery. Her Medicare coverage 

ended when she no longer needed skilled care. She chose 

to go home rather than pay for custodial care. After 65 

days, she was hospitalized for 3 days due to a fall. She 

was then admitted to a SNF because she needed skilled 

care. Since she was out of the SNF for more than 60 

days, her benefit period ended. Her new 3-day qualifying 

hospital stay starts a new benefit period. Medicare will 

cover up to 100 days of SNF care in this new benefit 

period. 

If I am in a SNF but must be readmitted to 

the hospital, will the SNF hold my bed for 

me? 

There may be no guarantee that a bed will be available 

for you at the same SNF if you need more skilled care 

after your hospital stay. You may have to go to another 

SNF if no bed is available. Ask the SNF if it will hold a 

bed for you if you must go back to the hospital. Also ask 

if there is a cost to hold the bed for you. 

Terms in red 

are defined on 

pages 40-42. 

12 Medicare Coverage of Skilled Nursing Facility Care 
Section 2 - Medicare SNF Coverage 

What does Medicare cover when I qualify for SNF care?


Medicare ServicesCovered

Semi-private room 

(a room you share with other patients) ✔ 

Meals ✔ 

Skilled Nursing Care ✔ 

Physical Therapy* ✔ 

Occupational Therapy* ✔ 

Speech-Language Therapy* ✔ 

Medical Social Services ✔ 

Medications ✔ 

Medical Supplies and Equipment Used in Facility ✔ 

Ambulance Transportation (when other transportation 

endangers health) to the nearest supplier of needed services 

that are not available at the SNF ✔ 

Dietary Counseling ✔ 

*Medicare covers these services if they are needed to meet your health goal.


Medicare Coverage of Skilled Nursing Facility Care

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Section 3 - What You Pay

For Days Medicare Pays For You Pay For 

Covered Services 

1-20 Full Cost Nothing 

21-100 All but $101.50 per day Up to $101.50 per day 

Beyond 100 Nothing Full Cost 

What do I pay for SNF care? 

In the Original Medicare Plan, for each benefit period in 

the calendar year 2002 you pay: 

Covered Services 

You must also pay all additional charges not covered by 

Medicare (like telephone charges and laundry fees). 

Payment Example 1 - SNF Stay 1-20 Days: 

Mr. Anderson is in the hospital for 5 days and is then 

admitted to a SNF (within 30 days of leaving the 

hospital). He is in the SNF for 12 days. Mr. Anderson 

will not have to pay anything for this Medicare-covered 

SNF care. He has 88 days of coverage left in this benefit 

period. 

Days in Days in Mr. Anderson Pays Days Left in 

Hospital SNF for SNF Care Benefit Period 

5 12 $0 for covered services* 88 

*See NOTE on next page. 

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Medicare Coverage of Skilled Nursing Facility Care
Section 3 - What You Pay

What do I pay for SNF care? (continued) 

Payment Example 2 - SNF Stay 21-100 Days: 

Mrs. Baker is in the hospital for 5 days. She is then 

admitted to a SNF (within 30 days of leaving the 

hospital). She is in the SNF for 30 days. Mrs. Baker will 

have to pay up to $1015 (the $101.50 a day coinsurance 

for days 21-30) for her Medicare-covered SNF care. She 

has 70 days of coverage left in this benefit period. 

Days in Days in Mrs. Baker Pays for Days Left in 

Hospital SNF SNF Care Benefit Period 

5 30 Up to $1,015* for covered 70 

services ($101.50 per day 

for days 21-30) 

*NOTE: Your SNF costs may be different if you are in 

a Medicare managed care plan or a Medicare Private Feefor-Service plan. Check with your plan. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 15
Section 3 - What You Pay 

Terms in red 

are defined on 

pages 40-42. 

16 

Are there ways to get help paying for

skilled care or other health care costs?

Yes. There are ways to get help paying for skilled care 

and other health care costs: 

Help from your state:If your income and assets are limited, you 

may be able to get help to pay for skilled and/or custodial care, or 

other health care costs. If you qualify for both Medicare and 

Medicaid, most health care costs are covered. You may also 

qualify for the Medicaid nursing home benefit or the Program of 

All-Inclusive Care for the Elderly (PACE). Call your state 

medical assistance office for more information (see pages 36-39). 

Employer or Union Coverage: If you have coverage 

from an employer or union, check with your benefits 

administrator to see what health care is covered. 

Medigap Policy: If you are in the Original Medicare Plan, 

you may have a Medigap policy to fill gaps in your 

coverage. Some Medigap policies pay the SNF coinsurance 

for days 21-100. For more information about Medigap 

policies, call 1-800-MEDICARE (1-800-633-4227) and ask 

for a free copy of the Guide to Health Insurance for People 

with Medicare: Choosing a Medigap Policy. You can also 

look at www.medicare.gov on the Internet. Click on 

Medigap Compare. 

Long-term Care Insurance: If you have long-term care 

insurance, check your policy or call the insurance company 

to find out if skilled or custodial care is covered. If you are 

shopping for long-term care insurance, find out which types 

of long-term care services the different policies cover. For 

more information about long-term care insurance, call to get 

a copy of The Shopper’s Guide to Long-Term Care 

Insurance from your State Insurance Department, or ask for 

one in writing from the National Association of Insurance 

Commissioners, 2301 McGee Street, Suite 800, Kansas 

City, MO 64108-3600. 

For more information about help paying for health care, 

call your State Health Insurance Assistance Program (see 

pages 36-39). 

Medicare Coverage of Skilled Nursing Facility Care 
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Section 4 - Your Care in a SNF 

Your assessments 

determine how much 

Medicare pays the 

SNF, based on the 

services and 

resources you need. 

The care you get in a SNF:	

• Is based on your daily assessments (see below).	

• Is planned to meet your needs (see “care plan” on page 18).	

What is an assessment? 

When you go to a SNF, a team of staff from different 

medical fields (depending on your health needs) plans 

your care. Your SNF care is based on your doctor’s 

orders and information the team gathers when they do 

daily assessments of your condition. Your doctor and the 

SNF staff use the assessments to decide what services 

you need and your health goal or goals. A health goal is 

the expected result of your treatment, like being able to 

walk a certain distance or to climb stairs. 

Your daily assessments and skilled care start the day you 

arrive at the SNF. Medicare requires that your 

assessments be recorded periodically. The first recorded 

assessment must be within the first 5-8 days of your SNF 

stay. Medicare also requires the SNF to record 

assessments done on days 14, 30, 60, and 90 of your 

covered stay (until you are discharged or you have used 

all 100 days of SNF coverage in your benefit period). 

An assessment includes gathering information about: 

• your current physical and mental condition; 

• your medical history; 

• medications you are taking; 

• how well you can do activities of daily living like 

getting dressed, combing your hair, walking, eating, 

and using the toilet; 

• your speech; 

• your decision-making ability; and 

•

physical limitations (like problems with your hearing 

or vision, paralysis after a stroke, balance problems, 

etc.). 

Medicare Coverage of Skilled Nursing Facility Care 17 
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Section 4 - Your Care in a SNF 

Take an active role in

the planning of your

care. It helps you

know what to expect.

What is a care plan? 

When your health condition is assessed, SNF staff 

prepares or updates your care plan. You (if you are able)

and/or your family, or someone acting on your behalf,

have the right to take part in planning your care

together with the SNF staff.Let the staff know if you 

want to take part. This helps keep you aware of how the 

care you get will help you reach your health care goals. 

Your care plan may include:

• What kind of services you need; 

• What type of health care professional should give you 

these services; 

• How often you will need the services; 

• What kind of equipment or supplies you need (like a 

wheelchair or feeding tube); 

• If you need a special diet; and 

• Your health goal (or goals), and how your care plan 

will help you reach your goal. 

Your Medicare coverage:

Continues if:

• You have used less than 

100 days of coverage in 

this benefit period, and 

• You still need skilled 

care or skilled 

rehabilitation on a daily 

basis. 

Ends if:

• You have used all 100 

days of coverage in the 

benefit period, or 

• You no longer need 

skilled care. 

Terms in red 

are defined on 

pages 40-42. 

18 

NOTE:If you refuse your daily skilled care or

therapy, you may lose your Medicare SNF coverage. If

your condition won’t allow you to get skilled care (for

instance if you get the flu) you may be able to continue

to receive Medicare coverage temporarily. 

Medicare Coverage of Skilled Nursing Facility Care
•

•

•

•

•

Section 5 - When Your Medicare Coverage Ends

How will I know when my Medicare SNF 

coverage is ending? 

If you are in the Original Medicare Plan and no longer 

qualify for Medicare coverage, you must be given a 

written “Notice of Medicare Non-Coverage.” The 

purpose of this notice is to let you know that the SNF 

believes you no longer qualify for SNF services paid by 

Medicare. If someone is acting on your behalf, the 

facility must notify them in writing. Medicare coverage 

ends the day after you get the notice. 

The Medicare Notice of Medicare Non-Coverage must 

tell you: 

•	 The date your Medicare coverage will end (and you 

must start to pay); 

• Why your stay is not (or is no longer) covered; 

•	 Your right to request that the SNF send Medicare its 

opinion that your care no longer meets Medicare 

coverage requirements (see page 21). 

•	 That, if you request a Demand Bill (see page 21), you 

are not required to pay for your SNF stay until you are 

informed of Medicare’s decision (you do have to pay 

any coinsurance charged and for services and supplies 

not covered by Medicare); and 

•	 Where you (or someone acting on your behalf) should 

sign to show you got the notice. 

NOTE: If you are in a Medicare managed care plan or a 

Private Fee-for-Service plan, check with your plan to find 

out how they will let you know your Medicare coverage is 

ending. You can ask for advance notice of non-coverage 

from the plan or the SNF. If you don’t agree with the 

decision, you may then file an appeal (see page 21). 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 19
Section 5 - When Your Medicare Coverage Ends


You can choose to pay for skilled care yourself when

your Medicare SNF care coverage ends. Check with the

SNF to see how much it costs. Long-term care can be

very expensive. See page 16 for information on ways

you may get help to pay skilled and custodial nursing

care costs.

Plan Ahead 

IT IS IMPORTANT TO PLAN AHEAD 

Try to plan ahead for any services you may need when

you leave the SNF. If you will be going home, you

may need help with grocery shopping, bathing and

dressing, or transportation. Or, you may need to think

about home health care (see page 35). 

If you need custodial carein a nursing facility after you

are discharged from the SNF, you may want to start

thinking about where you want to go. If the SNF you

are in has an unskilled bed available, and you are

happy with the care you have had so far, you may wish

to stay there. 

Remember, Medicare does not cover custodial care 

if that is the only kind of care you need. 

Terms in red

are defined on

pages 40-42.

20 Medicare Coverage of Skilled Nursing Facility Care 
Section 5 - When Your Medicare Coverage Ends	

If Medicare decides 

your care is no longer 

covered, you are 

responsible for the 

cost of the care you 

got while you were 

waiting for the 

decision. 

Terms in red 

are defined on 

pages 40-42. 

What if I think I still need SNF care? 

The SNF staff gives you a Notice of Medicare NonCoverage when they think you no longer qualify for 

Medicare coverage. But if you think that you still need 

SNF care, you have the right to have Medicare review the 

SNF’s opinion to decide if you still qualify for Medicare 

coverage. 

To have Medicare decide if you still qualify for SNF 

coverage: 

1. 	The SNF must send a special kind of claim to 

Medicare. This special claim is sometimes called a 

Demand Bill. Check off the appropriate box on the 

Notice of Non-Coverage to indicate that you want a 

Demand Bill sent to Medicare. 

2. Give the Notice to the SNF. 

3. 	The SNF sends the special claim (Demand Bill) to 

Medicare. 

4. 	Medicare decides if you still qualify for Medicarecovered SNF care. 

5. The SNF will let you know what the decision is. 

The SNF cannot make you pay a deposit for services that 

Medicare may not cover until Medicare makes its 

decision. You must continue to pay any costs that you 

would normally have to pay while the Demand Bill is 

being processed. This includes the daily coinsurance and 

the costs for services and supplies not covered by 

Medicare. 

You can file an appeal if you do not agree with this 

decision. To find out how to appeal, read the back of the 

Medicare Summary Notice or Notice of Utilization you 

get from the company that handles bills for Medicare. 

Medicare Coverage of Skilled Nursing Facility Care 21 
•

•

•

•

•

•

Section 6 - Your Rights and Protections 

What are my rights in a SNF? 

SNF residents have certain rights and protections under 

the law. SNFs must tell you these rights and give a copy 

of them to all new residents. 

Resident rights include: 

• Respect: You have the right to be treated with dignity 

and respect. 

• Services and Fees: You must be informed in writing 

about services and fees before you enter the nursing 

home. 

• Money: You have the right to manage your own 

money or to choose someone else you trust to do this 

for you. 

• Privacy: You have the right to privacy, and to keep 

and use your personal belongings and property as long 

as they don’t interfere with the rights, health, or safety 

of others. 

• Medical Care: You have the right to be informed 

about your medical condition, your medications, and 

to see your own doctor. You also have the right to 

refuse medications and treatments (but this could be 

harmful to your health). 

• Activities: You have the right to spend day-to-day 

time in a way that means something to you. 

More information about Medicare rights, protections, and 

appeals is available in Your Medicare Rights and 

Protections. Call 1-800-MEDICARE (1-800-633-4227) 

and ask for a free copy. You can also read or print this 

from www.medicare.gov on the Internet. 

22 Medicare Coverage of Skilled Nursing Facility Care 
•

•

•

•

•

•

Section 6 - Your Rights and Protections 

You are also protected against unfair transfer or 

discharge. You cannot be sent to another facility or 

made to leave the SNF unless: 

• The nursing home cannot give you the care you need. 

• You no longer need SNF care. 

•	 Your safety or the safety of others in the facility is in 

danger. 

•	 The health of others in the facility would be in danger 

if you stayed. 

• The facility closes. 

•	 You do not pay for the services you are responsible 

for. 

A facility cannot make you leave if you have submitted 

to Medicaid or another third-party payor all the paper 

work needed for your bill to be paid. The facility should 

work with other state agencies to get payment if your 

money is being held by a family member or another 

individual. 

NOTE: If you are in a Medicare Private Fee-for-Service 

plan, check with the plan to learn what your protections 

are. 

Terms in red 

are defined on 

pages 40-42. 

Medicare Coverage of Skilled Nursing Facility Care 23 
Section 6 - Your Rights and Protections 

What can I do if I am concerned about the 

quality of my care? 

If you believe that the SNF is not giving you good quality 

care, call the Long-term Care Ombudsman or Quality 

Improvement Organization for your state (see pages 36-

39). You may also make a complaint to the State Survey 

Agency. This is the State agency that conducts nursing 

home inspections. They must investigate complaints that 

indicate that a SNF may not be following Medicare 

requirements. Every SNF must post the phone number of 

the State Survey Agency in a public place. 

What if I think my SNF charges are wrong? 

If you are in the Original Medicare Plan, you will get 

either an Explanation of Medicare Benefits, a Medicare 

Summary Notice, or a Notice of Utilization from a 

company that handles Medicare bills for all your SNF 

charges. If you think these charges are wrong, call the 

company that sent you the notice. Its phone number is on 

the notice. 

NOTE: If you are in a Medicare managed care plan or a 

Private Fee-for-Service plan, call your plan if you have 

questions about your bills. 

Terms in red 

are defined on 

pages 40-42. 

24 Medicare Coverage of Skilled Nursing Facility Care 
•

•

•

Section 7 - Nursing Home Checklist 

Nursing Home Checklist 

Checklists can help you evaluate the nursing homes that you visit. Use a new 

checklist for each home you call or visit. Then, compare the scores. This will help 

you select a nursing home that is a good choice for you or your relative. 

Nursing Home Name: __________________________ Date Visited: __________ 

Address:______________________________________________________________ 

I. Basic Information: 

1. Is the facility Medicare certified? ____(yes) _____(no) 

2. Is the facility Medicaid certified? ____(yes) _____(no) 

3. Is this a skilled nursing facility? ____(yes) _____(no) 

4. Is this facility accepting new patients? ____(yes) _____(no) 

5. Is there a waiting period for admission? ____(yes) _____(no) 

6. Is a skilled bed available for you? ____(yes) _____(no) 

USEFUL TIPS 

•	 Generally, skilled care is available only for a short period of time after a 

hospitalization. Custodial care may be needed for a much longer period of time. 

If a facility offers both types of care, learn if residents may transfer between 

levels of care within the nursing home without having to move from their old 

room or from the nursing home. 

•	 Nursing homes that only take Medicaid residents might offer longer term but 

less intensive levels of care. Nursing homes that don’t accept Medicaid payment 

may make a resident move when Medicare or the resident’s own money runs 

out. 

•	 An occupancy rate is the total number of residents currently living in a nursing 

home divided by the home’s total number of beds. Occupancy rates vary by 

area, depending on the overall number of available nursing home beds. 

Medicare Coverage of Skilled Nursing Facility Care 25 
•

•

•

•

•

Section 7 - Nursing Home Checklist 

II. Nursing Home Information:

1. Is the home and the current administrator licensed? ____(yes) _____(no) 

2. Does the home conduct background checks on all staff? ____(yes) _____(no) 

3. Does the home have special service units? ____(yes) _____(no) 

4. Does the home have abuse prevention training? ____(yes) _____(no) 

USEFUL TIPS

•	 LICENSURE:

The nursing home and its administrator should be licensed by 

the State to operate. 

•	 BACKGROUND CHECKS:

Do the nursing home’s procedures to screen 

potential employees for a history of abuse meet your State’s requirements? 

Your State’s Ombudsman program might be able to help you with this 

information. 

•	 SPECIAL SERVICES:

Some nursing homes have special service units, like 

rehabilitation, Alzheimer’s, and hospice. Learn if there are separate waiting 

periods or facility guidelines for when residents would be moved on or off the 

special unit. 

•	 STAFF TRAINING: Do the nursing home’s training programs educate 

employees about how to recognize resident abuse and neglect, how to deal with 

aggressive or difficult residents, and how to deal with the stress of caring for so 

many needs? Are there clear procedures to identify events or trends that might 

lead to abuse and neglect, and on how to investigate, report, and resolve your 

complaints? 

•	 LOSS PREVENTION: Are there policies or procedures to safeguard resident 

possessions? 

26 Medicare Coverage of Skilled Nursing Facility Care
Section 7 - Nursing Home Checklist 

For Parts III through VI, give the nursing home a grade from one to five. One is 

worst, five is best. 

III. Quality of Life:

1. 	Residents can make choices about their daily 

routine. Examples are when to go to bed or get up, 

when to bathe, or when to eat. 

2. 	The interaction between staff and patient is warm 

and respectful. 

3. The home is easy to visit for friends and family. 

4. 	The nursing home meets your cultural, religious, or 

language needs. 

5. 	The nursing home smells and looks clean and has 

good lighting. 

6. The home maintains comfortable temperatures. 

7. 	The resident rooms have personal articles and 

furniture. 

8. 	The public and resident rooms have comfortable 

furniture. 

9. 	The nursing home and its dining room are generally 

quiet. 

10. 	Residents may choose from a variety of activities 

that they like. 

11. The nursing home has outside volunteer groups. 

12. 	The nursing home has outdoor areas for resident use 

and helps residents to get outside. 

WORST BEST

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

TOTAL______________

(Best Possible Score: 60)

Medicare Coverage of Skilled Nursing Facility Care

27 
•

Section 7 - Nursing Home Checklist 

IV. Quality of Care: 

1. 	The facility corrected any Quality of Care 

deficiencies that were in their latest State inspection 

report. 

2. 	Residents may continue to see their personal 

physician. 

3. 	Residents are clean, appropriately dressed, and well 

groomed. 

4. 	Nursing home staff respond quickly to requests for 

help. 

5. 	The administrator and staff seem comfortable with 

each other and with the residents. 

6. Residents have the same care givers on a daily basis. 

7. 	There are enough staff at night and on week-ends or 

holidays to care for each resident. 

8. 	The home has an arrangement for emergency 

situations with a nearby hospital. 

9. 	The family and residents councils are independent 

from the nursing home’s management. 

10. 	Care plan meetings are held at times that are easy for 

residents and their family members to attend. 

USEFUL TIP 

WORST BEST 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

TOTAL______________ 

(Best Possible Score: 50) 

• Good care plans are essential to good care. They should be put together by a team of 

providers and family and updated as often as necessary. 

28 Medicare Coverage of Skilled Nursing Facility Care 
•

•

•

•

Section 7 - Nursing Home Checklist 

V. Nutrition and Hydration (Diet and Fluids): 

1. 	The home corrected any deficiencies in these areas 

that were on the recent state inspection report. 

2. 	There are enough staff to assist each resident who 

requires help with eating. 

3. 	The food smells and looks good and is served at 

proper temperatures. 

4. Residents are offered choices of food at mealtimes. 

5. Residents’ weight is routinely monitored. 

6. 	There are water pitchers and glasses on tables in the 

rooms. 

7. 	Staff help residents drink if they are not able to do so 

on their own. 

8. 	Nutritious snacks are available during the day and 

evening. 

9. 	The environment in the dining room encourages 

residents to relax, socialize, and enjoy their food. 

WORST BEST 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

TOTAL______________ 

(Best Possible Score: 45) 

USEFUL TIPS 

• Ask the professional staff how the medicine a resident takes can affect what 

they can eat and how often they may want something to drink. 

• Visit at mealtime. Are residents rushed through meals or do they have time to 

finish eating and to use the meal as an opportunity to socialize with each other? 

• Sometimes the food a home serves is fine, but a resident still won’t eat. Nursing 

home residents may like some control over their diet. Can they select their 

meals from a menu or select their mealtime? 

• If residents need help eating, do care plans specify what type of assistance they 

will receive? 

Medicare Coverage of Skilled Nursing Facility Care 29

Section 7 - Nursing Home Checklist 

VI. Safety: WORST BEST 

1. There are handrails in the hallways and grab bars in 1 2 3 4 5 

the bathrooms. 

2. Exits are clearly marked. 1 2 3 4 5 

3. Spills and other accidents are cleaned up quickly. 1 2 3 4 5 

4. Hallways are free of clutter and well lighted. 1 2 3 4 5 

5. 	There are enough staff to help move residents quickly 1 2 3 4 5 

in an emergency. 

6. The nursing home has smoke detectors and sprinklers. 1 2 3 4 5 

TOTAL______________ 

(Best Possible Score: 30) 

30 Medicare Coverage of Skilled Nursing Facility Care 
 

 

31

VII. 

There is information at www.medicare.gov on the

Internet that may be helpful when you compare nursing

homes. 

summary information about nursing homes from their

last state inspection. It also contains information that was

reported by the nursing homes prior to the last state

inspection, including information on nursing home and

resident characteristics. If you have questions or concerns

about the information on a nursing home, you should

discuss them during your visit. 

computer, your local library or senior center may be able

to help you get this information.

When you call or visit a nursing home:

• Have a copy of the Nursing Home Compare inspection

results for the nursing home. Ask whether the

deficiencies have been corrected. 

• Ask to see a copy of the most recent nursing home

inspection report. 

Section 7 - Nursing Home Checklist

Look at

www.medicare.gov on

the Internet. Click on

Nursing Home

Compare to get the

most recent

inspection

information on the

facilities you are

interested in.

Medicare Coverage of Skilled Nursing Facility Care

Nursing Home Inspection Results on the Internet

Click on Nursing Home Compare. You will find

If you don’t have a
•

•

•

•

•

•

•

Section 7 - Nursing Home Checklist 

The following questions relate to Nursing Home 

Compare’s Information on Resident and Nursing 

Home Characteristics. 

For the Measure: Residents Who Are Very 

Dependent in Eating 

• Look at your response to Question 2 in Section VNutrition and Hydration. 

• Are residents who need help eating able to finish their 

meals, or is the food returned to the kitchen uneaten? 

For the Measure: Residents Who Are Bedfast (must 

stay in bed) 

• Ask the Director of Nursing “How are staff assigned 

to care for these residents?” 

For the Measure: Residents With Restricted Joint 

Motion 

• Ask the Director of Nursing “How does the nursing 

home care for residents with restricted joint motion?” 

• Do the residents get help getting out of chairs and beds 

when they want to get up? 

For the Measure: Residents with Restraints 

• Compare the percentage of residents in a specific 

nursing home who are physically restrained with the 

state and national averages shown. If the nursing 

home’s percentage is high, you may want to discuss 

this with the Director of Nursing. You may notice that 

there are restraint-free facilities. 

• Ask staff what reasons would trigger using a restraint 

on a resident, and to what extent they first try to use 

Terms in red less restrictive devices? Also ask how they go about 

are defined on removing restraints. 

pages 40-42. 

32 Medicare Coverage of Skilled Nursing Facility Care 
•

•

•

•

•

•

•

•

•

Section 7 - Nursing Home Checklist 

For the Measure: Residents with Restraints 

(continued) 

• Does it look like there is enough staff to help residents 

with moving or getting in and out of chairs and bed? 

• Ask the Director of Nursing “Who is involved in the 

decisions about restraints used for a particular 

resident?” 

• If restraints are used, do the staff remove the restraints 

on a regular basis to help residents with moving, and 

with activities of daily living? 

• Do staff help residents with restraints to get in and out 

of bed and chairs when they want to get up? 

• Do staff help residents with restraints to move as much 

as they would like to? 

• Ask if the facility has a “restraint reduction program” 

in place and if they are working toward becoming 

restraint-free. 

For the Measure: Residents with Pressure (Bed) Sores 

• Ask the staff how they identify if a resident is at risk 

for skin breakdown. Ask them what they do to prevent 

pressure sores for these residents. 

• Ask the staff how many of their residents have 

pressure sores and why. 

• Do you see staff helping residents change their 

positions in wheelchairs, chairs, and beds? 

Medicare Coverage of Skilled Nursing Facility Care 33 
•

•

•

•

•

•

•

Section 7 - Nursing Home Checklist 

For the Measure: Residents with Urinary 

Incontinence 

• Does the nursing home smell clean? 

• Ask the staff what steps they take to prevent 

incontinence for residents who are at risk. 

For the Measure: Residents with Unplanned Weight 

Gain or Loss 

• Look at your answers to Questions 2, 3, 4, 5, 8, and 9 

in Section V-Nutrition and Hydration. 

For the Measure: Residents with Behavioral 

Symptoms 

• What management and/or medical approaches for 

behavioral symptoms are being used by the nursing 

home? 

• How do staff handle residents that have behavioral 

symptoms such as calling out or yelling? 

• Ask whether residents with behavioral symptoms are 

checked by a doctor or behavioral specialist. 

• Ask whether staff get special training to help them 

care for residents with behavioral symptoms. 

Terms in red 

are defined on 

pages 40-42. 

34 Medicare Coverage of Skilled Nursing Facility Care 
•

•

•

•

•

•

•

Section 8 - For More Information 

To order free booklets for more information 

about Medicare-related topics: 

Call 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 

1-877-486-2048 for the hearing and speech impaired) and 

ask for a copy of: 

• Do you need help to pay your health care costs? -

This flyer gives information about programs in your 

state (Medicaid) that can help you pay health care 

costs. 

• Guide to Health Insurance for People with 

Medicare: Choosing a Medigap Policy - This 

booklet gives information on buying and using a 

Medigap policy and other types of insurance. 

• Medicare and Other Health Benefits: Your Guide 

to Who Pays First - This booklet explains how 

Medicare works with other types of insurance, and 

who pays first. 

• Medicare & You - This handbook gives basic 

information about Medicare coverage and benefits, 

health plan choices, protections and rights, and more. 

• Medicare Home Health Care Services - This booklet 

explains Medicare coverage of home health care. 

• Medicare Hospice Benefits - This booklet explains 

Medicare coverage of hospice care for people who 

have a terminal illness. 

• Your Guide to Choosing a Nursing Home - This 

booklet helps you with the process of choosing a 

nursing home. 

You can also look on the Internet at www.medicare.gov 

to read or print these booklets, or for other information 

about Medicare and related topics. 

Medicare Coverage of Skilled Nursing Facility Care 35 

Terms in red 

are defined on 

pages 40-42. 
Section 8 - For More Information 

Important Telephone Numbers 

The next three pages have the telephone numbers for 

some organizations that can help you with your questions 

about SNFs, SNF care, and other related topics. These 

numbers are for the Long-term Care Ombudsman, Quality 

Improvement Organization, State Medicare Assistance 

Office, and the State Health Insurance Assistance 

Program in each state. Each organization helps answer 

different types of questions as explained below. 

Organization Call with your question about: 

Long-term Care 

Ombudsman 

Quality Improvement 

Organization 

State Medical 

Assistance Office 

State Health Insurance 

Assistance Program 

• SNFs and nursing homes 

• Problems with your care 

• Quality of your care 

• State programs that help pay 

health care costs 

• Medicare 

• Medigap and other insurance 

policies 

• Your rights 

• Your care 

• Choosing a health plan 

• Medicare bills 

NOTE: The telephone numbers on the next three pages 

were correct at the time of printing. Phone numbers 

sometimes change. To get the most up-to-date phone 

numbers, call 1-800-MEDICARE (1-800-633-4227, or 

TTY/TDD 1-877-486-2048 for the hearing and speech 

impaired) or go to the Internet at www.medicare.gov and 

click on Helpful Contacts. 

Terms in red 

are defined on 

pages 40-42. 

36 Medicare Coverage of Skilled Nursing Facility Care 
Section 9 - Definitions of Important Terms 

Appeal - A special kind of complaint 

you make if you disagree with any 

decision about your health care 

services. For example, if Medicare 

doesn’t pay for a service you got. 

There is usually a special process you 

must use to make your complaint. 

Benefit Period - The way that 

Medicare measures your use of hospital 

and skilled nursing facility (SNF) 

services. For SNF care, a benefit period 

begins the day you are admitted to a 

SNF. The benefit period ends when you 

have not received hospital care or 

skilled care in a skilled nursing facility 

for 60 days in a row. If you have a 

qualifying stay in a hospital after one 

benefit period has ended, a new benefit 

period begins. 

For each benefit period of SNF care, 

you pay nothing for days 1-20 and 

$101.50 per day (in 2002) for days 21-

100. There is no limit to the number of 

benefit periods you can have. 

Coinsurance - The percent of the 

Medicare-approved amount that you 

have to pay after you pay the deductible 

for Part A and/or Part B. In the Original 

Medicare Plan, the coinsurance 

payment is a percentage of the cost of 

the service (like 20% for Part B 

services). 

Custodial Care - Personal care, such


as bathing and cooking. This is not


covered by Medicare.


Hydration - The level of fluid in the


body. The loss of fluid, or dehydration,


occurs when you lose more water or


fluid than you take in. Your body


cannot keep adequate blood pressure,


get enough oxygen and nutrients to the


cells, or get rid of wastes if it has too


little fluid.


Long-term Care Ombudsman - A


supporter for nursing home patients


who works to solve problems between


patients and nursing homes.


Medicaid - A joint Federal and State


program that helps with medical costs


for some people with low incomes and


limited resources. Medicaid programs


vary from state to state, but most health


care costs are covered if you qualify for


both Medicare and Medicaid.


Medicare Managed Care 


Plan - These are health care options in


some areas of the country. In most of


these plans, you can only go to doctors,


specialists, or hospitals on the plan’s


list. Plans must cover all Medicare Part


A and Part B health care. Some plans


cover extras, like prescription drugs.


Your costs may be lower than in the


Original Medicare Plan.


40 Medicare Coverage of Skilled Nursing Facility Care 
Section 9 - Definitions of Important Terms 

Medicare Part A (Hospital Insurance) -

Hospital insurance that pays for 

inpatient hospital stays, care in a skilled 

nursing facility, home health care and 

hospice care. 

Medicare Summary Notice (MSN) -

A notice you get after the doctor files a 

claim for Part A and Part B services 

under the Original Medicare Plan. It 

explains what the provider billed for, 

the approved amount, how much 

Medicare paid, and what you must pay. 

You might also get a notice called an 

Explanation of Medicare Benefits 

(EOMB) for Part B services, or a 

Notice of Utilization. 

Medigap Policy - A Medicare 

supplemental health insurance policy 

sold by private insurance companies to 

fill “gaps” in Original Medicare Plan 

coverage. Except in Massachusetts, 

Minnesota, and Wisconsin, there are 10 

standardized policies labeled Plan A 

through Plan J. Medigap policies only 

work with the Original Medicare Plan. 

Occupational Therapy - Services 

given to help you return to usual 

activities (such as bathing, preparing 

meals, housekeeping) after an illness 

either on an inpatient or outpatient basis. 

Original Medicare Plan - A pay-pervisit health plan that lets you go to any 

doctor, hospital, or other health care 

provider who accepts Medicare. You 

pay the deductible. Medicare pays its 

share of the Medicare-approved 

amount, and you pay your share 

(coinsurance). The Original Medicare 

Plan has two parts: Part A (Hospital 

Insurance) and Part B (Medical 

Insurance). 

Physical Therapy - Treatment of 

injury and disease by mechanical 

means, as heat, light, exercise, and 

massage. 

Private Fee-For-Service Plan - A 

private insurance plan that accepts 

Medicare beneficiaries. You may go to 

any doctor or hospital you want. The 

insurance plan, rather than the 

Medicare program, decides how much 

you pay for the services you receive. 

You may pay more for Medicare 

covered benefits. You may have extra 

benefits the Original Medicare Plan 

doesn’t cover. 

Program of All-Inclusive Care for the 

Elderly (PACE) - A special program 

that combines both outpatient and 

inpatient medical and long-term care 

services. To be eligible, you must be at 

least 55 years old, live in the service 

area of the PACE program, be certified 

as eligible for nursing home care by the 

appropriate state agency, and meet any 

other program-specific requirements. 

The goal of PACE is to keep you 

independent and living in your 

community as long as possible, and to 

provide quality care at low cost. 

Medicare Coverage of Skilled Nursing Facility Care 41

Section 9 - Definitions of Important Terms 

Quality Improvement 

Organization (QIO) - Groups of 

practicing doctors and other health 

care experts. They are paid by the 

federal government to check and 

improve the care given to Medicare 

patients. They must review your 

complaints about the quality of care 

provided by inpatient hospitals, 

hospital outpatient departments, 

hospital emergency rooms, skilled 

nursing facilities, home health 

agencies, Medicare managed care 

plans, Private Fee-for-Service plans, 

and ambulatory surgical centers. 

Speech-Language Therapy* - The 

study, examination, and treatment of 

defects and diseases of the voice, 

speech, and spoken and written 

language, as well as the use of 

appropriate substitutional devices 

and treatment. 

State Health Insurance Assistance 

Program (SHIP) - A State program 

that gets money from the federal 

government to give free health 

insurance counseling and assistance 

to people with Medicare. 

* This definition in whole or in part, was used with permission from Walter Feldesman, Esq., 

Dictionary of Eldercare Terminology, Copyright 2000. 

42 Medicare Coverage of Skilled Nursing Facility Care 
Index 

1-800-MEDICARE . . . . 6, 16, 22, 35 

Ambulance . . . . . . . . . . . . . . . . . . . 13 

Appeals . . . . . . . . . . . . . . . . 19, 21, 40 

Assessment . . . . . . . . . . . . . . . . 17, 18 

Audiologist . . . . . . . . . . . . . . . . . . . . 3 

Background Checks . . . . . . . . . . . . 26 

Benefit Period . . . . . . 8-12, 14, 15, 40 

Care Plan . . . . . . . . . . . . . . . . . . . . 18 

Coinsurance . . . . . . . . . . . . 15, 21, 40 

Coverage . . . . . . . . . . . . . . . . . 2, 8-13 

Qualifying for . . . . . . . . . . . . . . . . 8 

When it ends . . . . . . . . . . . . . 19-21 

Custodial Care . . . . . . . . . . . 1, 20, 40 

Demand Bill . . . . . . . . . . . . . . . 19, 21 

Dietary Counseling . . . . . . . . . . . . . 13 

Employer Coverage . . . . . . . . . . . . 16 

Guide to Health Insurance 

for People with Medicare . . . . . . 16 

Health Goal . . . . . . . . . . . . . 4, 17, 18 

Hydration . . . . . . . . . . . . . . . . . 29, 40 

Internet . . . . . . . . . . . . . . 6, 16, 22, 31 

Licensed Practical Nurse . . . . . . . . . 3 

Licensure . . . . . . . . . . . . . . . . . . . . 26 

Long-Term Care Insurance . . . . . . 16 

Long-Term Care 

Ombudsman . . . . . 6, 24, 36-39, 40 

Loss Prevention . . . . . . . . . . . . . . . 26 

Meals . . . . . . . . . . . . . . . . . . . . 13, 29 

Medicaid . . . . . . . . . . . . . . . 16, 23, 40 

Medical Equipment . . . . . . . . . . . . 13 

Medical Social Services . . . . . . . . . 13 

Medical Supplies . . . . . . . . . . . . . . 13 

Medicare Booklets . . . . . . . . . . . . . 35 

Medicare Managed Care 

Plan . . . . . . . . . . 2, 5, 15, 19, 24, 40 

Medicare Part A . . . . . . . . . . . . . 8, 41 

Medicare Summary Notice . 21, 24, 41 

Medications . . . . . . . . . . . . . . . . . . 13 

Medigap Policy . . . . . . . . . . 2, 16, 41 

Notice of Medicare 

Non-Coverage . . . . . . . . . . . . 19-21 

Notice of Utilization . . . . . . . . . 21, 24 

Nursing Home Checklist . . . . . . 25-34 

Nutrition . . . . . . . . . . . . . . . . . . . . . 29 

Occupational Therapist . . . . . . . . . . . 3 

Occupational Therapy . . . . . . . 13, 41 

Office on Aging . . . . . . . . . . . . . . . . 6 

Original Medicare Plan . . . . . . . 2, 41 

Physical Therapist . . . . . . . . . . . . . . 3 

Physical Therapy . . . . . . . . . . . . . . 41 

Private Fee-for-Service 

Plan . . . . . . . 2, 5, 15, 19, 23, 24, 41 

Program of All-inclusive Care 

for the Elderly (PACE) . . . . . 16, 41 

Quality . . . . . . . . . . . . . . . . 24, 27, 28 

Quality Improvement 

Organization . . . . . . . 24, 36-39, 42 

Registered Nurses . . . . . . . . . . . . . . . 3 

Resident Rights . . . . . . . . . . . . . . . 22 

Safety . . . . . . . . . . . . . . . . . . . . . . . .30 

Skilled Care (Nursing and 

Rehabilitation) . . . . . . 1, 3, 4, 8, 13 

Skilled Nursing Facility (SNF) . 1, 5-7 

Social Security . . . . . . . . . . . . . . . . . 8 

Speech-Language Pathologist . . . . . 3 

Speech-Language Therapy . . . . . . . 13 

State Health Insurance Assistance 

Program . . . . . . . . 12, 31-33, 36-39 

State Medical Assistance 

Office . . . . . . . . . . . . . . . 16, 36-39 

The Shopper’s Guide to 

Long-Term Care Insurance . . . . 16 

Transfer . . . . . . . . . . . . . . . . . . . . . 23 

Union Coverage . . . . . . . . . . . . . . . 16 

Vocational Nurse . . . . . . . . . . . . . . . 3 

Your Guide to Choosing a Nursing 

Home . . . . . . . . . . . . . . . . . . . 6, 35 

Medicare Coverage of Skilled Nursing Facility Care 43 
•

•

U.S. DEPARTMENT OF


HEALTH AND HUMAN SERVICES


Centers for Medicare & Medicaid Services


7500 Security Boulevard


Baltimore, Maryland 21244-1850


Official Business


Penalty for Private Use, $300


Publication No. CMS 10153


Revised April 2002


•

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•

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45