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Dear Marci,

 

I will be having my hip replaced this year, and my doctor told me I will need to stay in the hospital and then likely recover in a skilled nursing facility (SNF). I have Original Medicare. How does it cover inpatient services like this?

 

-Fiona (Culver City, CA)

 

Dear Fiona,

 

Inpatient hospital care and care in a skilled nursing facility (SNF) are both Medicare Part A-covered services.

 

Part A covers medically necessary inpatient hospital care, which is care that you receive as a formally admitted hospital inpatient. You must be formally admitted into the hospital by a physician in order for your care to be considered inpatient hospital care. You may face different costs if you are a hospital outpatient, meaning you receive services at the hospital but are not formally admitted.

 

If you are a hospital inpatient, Part A covers:

  • A semi-private hospital room and meals
  • General nursing care
  • Medically necessary medications
  • Other hospital services and supplies

Medicare does not cover:

  • Private duty nursing
  • A private room (unless medically necessary or if it is the only room available)
  • Personal care items (such as razors or socks)
  • A television or telephone in your room

After meeting your Part A deductible, Original Medicare pays in full for the first 60 days of your benefit period. After day 60, you will pay a daily hospital coinsurance. Part B continues to cover any outpatient provider services you receive while in the hospital. You usually owe a separate 20% coinsurance for these services.

SNF care is post-hospital care provided at a SNF. Skilled nursing care includes services such as administration of medications, tube feedings, and wound care. Keep in mind that SNFs can be part of nursing homes or hospitals.

Medicare Part A may cover your SNF care if:

  • You were formally admitted as an inpatient to a hospital for at least three consecutive days
  • You enter a Medicare-certified SNF within 30 days of leaving the hospital, and receive care for the same condition that you were treated for during your hospital stay
  • And, you need skilled nursing care seven days per week or skilled therapy services at least five days per week

Note: the day you become an inpatient counts toward your three-day inpatient stay to qualify for Medicare-covered SNF care. However, the day you are discharged from the hospital does not count toward your qualifying days. Also remember that time spent receiving emergency room care or under observation status does not count toward the three-day hospital inpatient requirements for SNF coverage.

 

If you meet all of the above requirements, Medicare should cover the SNF care you need to improve your condition, maintain your ability to function, or prevent your health from getting worse.

 

During a Medicare-covered SNF stay, Part A covers:

  • A semi-private room and meals
  • Skilled nursing care provided by nursing staff
  • Therapy, including physical therapy, speech therapy, and occupational therapy
  • Medical social services and dietary counseling
  • Medications
  • Medical equipment and supplies
  • Ambulance transportation to the nearest provider or needed services, when other modes of transportation would endanger your health.

For each benefit period, Part A covers the full cost of your first 20 days in a SNF. For days 21-100, Part A covers part of the cost and you pay a daily coinsurance. If you need more than 100 days of SNF care in a benefit period, you will need to pay out of pocket.

 

-Marci

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