Registered nursing services fall under Medicare Part A, which is the hospitalization portion of the program.
The federal government recognizes that registered nursing services are vital in patient care for seniors and people with disabilities. Nonetheless, Medicare has rules that govern the conditions and settings that qualify for payment under Medicare.
Medicare recipients must understand the scope and limitations of nursing care services to maximize their benefits and arrange for necessary and appropriate medical care.
We’ll describe the registered nursing services Medicare covers, explain what Medicare does and doesn’t cover for those services, and outline other factors that may impact coverage for nursing care services.
The Centers for Medicare & Medicaid Services (CMS) calls registered nursing services skilled nursing care.
Under Medicare’s definition, skilled nursing care refers to nursing care and therapy that can only be performed by or under the supervision of technical personnel or professionals. It refers to a type of service you need to treat or manage your care. Skilled nursing care also covers professional services to observe or evaluate your care.
Contents
Medicare Cover
Medicare will cover the following services in a skilled nursing facility:
- A semi-private room (shared room)
- Meals
- Skilled nursing care
- Physical therapy (as necessary for health goals)
- Occupational therapy (as necessary for health goals)
- Speech-language pathology services (as necessary for health goals)
- Medical social services
- Medications
- Medical supplies and equipment used in the facility
- Ambulance transportation (if necessary for your health) to the nearest supplier of necessary services that aren’t available at a skilled nursing facility
- Dietary counseling
Medicare will also cover separate conditions that were also treated during a qualified inpatient hospital stay, even if they weren’t the original reason for entering the hospital.
For example, a patient may have diabetes that needs treatment after entering the hospital for a heart condition. If the diabetes flares up, Medicare will cover that as well.
You may have to follow different rules if you have a Medicare Advantage plan. That said, the government requires your plan to offer at least the same coverage as Original Medicare Part A. You can read more about Part A by visiting https://boomerbenefits.com/new-to-medicare/parts-of-medicare/medicare-part-a/.
Medicare’s conditions
For these services to be covered by Medicare, your physician or healthcare provider must determine that you need skilled care daily (e.g., intravenous medications or fluids, physical therapy, etc.). The person providing the services must be a skilled nursing or therapy staff member or be under their supervision.
Medicare will cover skilled nursing care or the therapies listed above as long as they improve or maintain your condition or prevent it from worsening.
The definition of skilled nursing care is just part of the equation. The rest concerns the specific rules relating to covered nursing care services.
What Medicare Covers for Registered Nursing Care
Be aware that Medicare only covers skilled nursing care services on a short-term basis. It’s also important to know that the out-of-pocket costs for inpatient hospital care are different than what you will pay for registered nursing care. You can find hospitalization costs at Medicare.gov.
To qualify for skilled nursing care, you must have an inpatient stay for at least three consecutive days (not including the day of discharge or time you spent in pre-admission in an emergency room or outpatient observation).
The three-day rule doesn’t apply if your physician participates in an Accountable Care Organization or another program approved for a Skilled Nursing Facility 3-Day Rule Waiver. Some Medicare Advantage Plans also waive the three-day minimum.
Skilled Nursing Costs with Medicare
You won’t pay anything during each benefit period from the first day to the 20th day. If you have a Medicare Advantage Plan, you may have to pay your copayments for those first 20 days. See your plan for the details.
Starting on the 21st day, you must pay $204 per day until the 100th day. You will be responsible for all the costs from the 101st day and following.
The benefit period starts when you are admitted to a medical or nursing facility. It ends when you have not needed hospital or skilled nursing care for 60 consecutive days.
If your benefit period ends and you become ill enough to re-enter a hospital or skilled nursing care facility, a new benefit period starts. Once again, you pay nothing for the first 20 days and $204 per day until the 100th day. You will pay all the costs after the 100th day.
When your physician or other healthcare provider recommends getting services more often than what Medicare covers, you may have to pay all or a portion of the costs. You will also need to pay for any services Medicare doesn’t cover.
To avoid extensive out-of-pocket costs, ask your healthcare provider why certain services are necessary, whether Medicare will pay for them, and how much your plan covers.
Factors That May Impact Costs and Coverage
Certain situations may make it unclear what Medicare will cover.
For example, if you are in a skilled nursing facility and need to reenter the hospital, your placement at the same skilled nursing facility may not be available if you need to return. You can ask the facility if they will hold a bed for you, but they may charge you for doing so.
Also, be clear about whether the medical staff considers you an inpatient or an outpatient. For example, suppose you spend one day in the emergency room getting observation services and are subsequently admitted to the hospital for two more days.
You won’t have met the three-day minimum hospital stay in that case. The reason is that you would be considered an outpatient for the first day in the emergency room.
Additionally, if you refuse physician-directed skilled nursing care or stop receiving skilled nursing care in a facility, you may lose your Medicare coverage.
Medicare and Registered Nursing Care: Final Things to Remember
To ensure coverage under Medicare, the skilled nursing services you need must be covered by Medicare and delivered by a physician or healthcare professional or work under their supervision.
Be aware of the three-day minimum inpatient stay and be clear on whether your stay is considered an inpatient or outpatient.
By understanding the rules for Medicare skilled nursing care and hospitalization, you can make good care decisions and minimize out-of-pocket costs.
