Introduction to Skilled Nursing Care

Skilled Nursing is a facility-based level of care paid for by Medicare (MC), Medicare Advantage programs, and Medicaid. A patient receiving skilled nursing care may be in a unit called the transitional care unit, or TCU, sub-acute, or step-down. Skilled services include management and evaluation of a patient’s care plan; observation and assessment of the patient’s changing condition; ongoing evaluation of rehabilitation needs and potential; therapeutic exercises or activities; gait evaluation and training; intravenous or intramuscular injections; and enteral feedings. 

Nurses at Skilled Nursing Facility learning Medicare Rules For Care Administration
Skilled Nursing Facilities - Rules For Care Administration

Short term (transitional) care is generally offered by Skilled Nursing Facilities, (SNF’s) while longer-term care is available from Nursing Homes. Skilled rehabilitative care services administered at an SNF must provide medically reasonable and necessary daily services for patients up to five days per week. Skilled nursing services must be offered up to seven days per week. Patients may leave the facility for appointments such as medical tests or consults; otherwise, the patient is to remain in the facility at all other times. If the patient wishes to leave the facility for any other reasons than medical care, such as a family gathering, the treating physician must write an order. These services are provided according to individual patient needs and following a care team’s recommendations. Not every patient receives rehab services five days a week, and nursing services seven days a week. 

Medicare Part A covers the patient’s stay in a SNF for up to 100 days during each spell of illness. If coverage criteria are met, the patient is entitled to full payment for the first 20 days of care. From the 21st through the 100th day, the patient is responsible for a daily coinsurance amount. The 100-day coverage resets after 90 days of wellness.

Medicare A will cover a SNF admission, but only if the patient stays at an inpatient hospital for at least three midnights. Only then can a patient be admitted to a skilled nursing facility within 30 days of their hospital discharge. 

It’s important to note a patient with a shorter hospital visit won’t meet the Medicare A criteria for a 3-day hospitalization and would be responsible for the cost of the SNF. Furthermore, the Medicare beneficiary or proxy must confirm the patient is admitted to a hospital by a physician as an inpatient, and not under “observation status.” Once admitted to a SNF, the treating physician must certify the need for a longer-term skilled level of care.

Medicare Advantage plans have enough flexibility that they may or may not require a three-midnight stay. Insurance companies administer Medicaid or Medicare Advantage plans and require regular updates on the patient’s condition, which are reviewed and recommended by their nurse case manager or medical director. Beneficiaries should contact their policyholder to confirm their benefits. Medicaid covers skilled nursing services per state rules.

Navigating the benefits system can be confusing and costly. Patients and their families or caregivers must be well-informed before they receive a large bill from the care facility.
Skilled nursing facilities employ professionals who are available and can assist with questions about the length of stay, coinsurance payments, and patient liability. 

(Source:, Updated March 2020)