Medicare and the skilled nursing facility: the 100 days, explained

“Medicare covers 100 days in a nursing home” is one of the most repeated and most misleading sentences in elder care. It is true in the way that “the speed limit is 85” is true on one road in Texas. The rules that surround it decide whether a family pays nothing or thousands, and most families learn them from a bill.

Medicare covers a skilled nursing facility (SNF) only after a hospital stay of at least three consecutive days as an inpatient, not counting the day of discharge. The trap is observation status: a patient can spend three nights in a hospital bed, receive tests and treatment, and never be formally admitted. Those days do not count. The hospital must give written notice (the MOON) if observation lasts more than 24 hours, but families often miss it. Before agreeing to a SNF, ask the case manager to confirm in writing that the stay qualifies. Some Medicare Advantage plans waive the three-day rule; ask.

Medicare pays for a SNF only while the patient needs skilled nursing or skilled rehabilitation services on a daily basis (therapy five or more days a week counts) that can practically only be provided in a facility. Skilled means services that require a nurse or therapist: wound care, IV medications, physical therapy after a hip fracture, monitoring of an unstable condition. It does not mean help with bathing, dressing, eating or walking, which Medicare calls custodial care and does not cover on its own.

The 100 days are per benefit period, not per year or per lifetime. A benefit period begins the day of admission to a hospital or SNF and ends when the patient has been out of both for 60 consecutive days. After that, a new benefit period starts, with a new hospital deductible and a new 100 days, if there is a new qualifying hospital stay. A patient who leaves a SNF and returns within 30 days can resume the same benefit period without a new hospital stay.

Most SNF stays end well before day 100, typically after two to four weeks, when the facility determines that daily skilled care is no longer needed. The facility must give a written Notice of Medicare Non-Coverage at least two days before covered care ends. That notice includes the right to a fast appeal through the Quality Improvement Organization, which must be requested by noon of the day before coverage ends. If you appeal, the facility cannot bill you for the disputed days until the QIO decides, usually within two days.

Appeal when the patient still clearly needs skilled care: active therapy goals, wounds, IVs, unstable conditions. Do not appeal simply to buy time for home arrangements; the QIO looks only at skilled need. If the reason for wanting more time is that home is not ready, that is a conversation with the facility social worker about discharge planning, and it should start on day one.

• A semi-private room, meals, skilled nursing, physical, occupational and speech therapy, medical social services, medications, medical supplies and equipment used in the facility, and ambulance transport when necessary.
• Not covered: a private room unless medically necessary, personal items, television and phone charges in some facilities, and custodial care once skilled need ends.

If your parent still needs facility care after Medicare coverage ends, the options are private pay (nursing homes commonly cost $8,000 to $12,000 a month), long-term care insurance if she has it, or Medicaid, which covers nursing home care for people who meet financial and medical eligibility. Medicaid rules are state-specific and complex; an elder-law attorney or a SHIP counselor can explain them, and applying early matters because approval takes time. If she can go home, home health, Medicaid home and community-based services, and family and private help are the routes. Plan for both possibilities from the first week.