Medicare Coverage for Skilled Nursing Facility (SNF) Extended Care: Eligibility and Services

The term “extended care services” refers to specific medical and rehabilitative services provided to an inpatient in a skilled nursing facility (SNF) that are covered by Medicare Part A. Understanding **Medicare SNF coverage rules** is crucial for beneficiaries, their families, and healthcare providers. These services are designed for individuals who require a level of care that can only be provided in an inpatient SNF setting, following a qualifying hospital stay. It’s important to note that Medicare regulations, particularly those concerning **skilled nursing facility eligibility criteria** and covered services, can be updated frequently. We always recommend checking the most current **official CMS guidelines** for the latest information.

What Are Medicare-Covered Extended Care Services in an SNF?

“Extended care services” encompasses a range of items and services furnished to an inpatient of a skilled nursing facility (SNF) either directly by the facility or through arrangements with other providers. These typically include:

• Nursing care provided by or under the supervision of a registered professional nurse;
• Bed and board in connection with furnishing such nursing care;
• Physical therapy, occupational therapy, and/or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements made by the facility;
• Medical social services;
• Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily provided by such facility for the care and treatment of inpatients;
• Medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement (see §50.7) under an approved teaching program of the hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect; and
• Other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements.

Medicare Part A Coverage for SNF Services: Eligibility and Requirements

Care in a Skilled Nursing Facility is covered under Medicare Part A if all of the following four factors, which define **skilled nursing facility eligibility criteria**, are met:

1. The patient requires skilled nursing services or skilled rehabilitation services. These are services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4). They must be ordered by a physician and rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which they received inpatient hospital services.
2. The patient requires these skilled services on a daily basis (see §30.6).
3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
4. The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury. This means they are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

For example, even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be considered “reasonable and necessary” for the treatment of a patient’s illness or injury if intermittent care is sufficient.

If any one of these four factors is not met, a stay in an SNF, even though it might include the delivery of some skilled services, is not covered. For instance, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

In reviewing claims for SNF services to determine whether the level of care requirements are met, the A/B MAC (A) (Medicare Administrative Contractor for Part A and Part B services) first considers whether a patient needs skilled care. If a need for a skilled service does not exist, then the “daily” and “practical matter” requirements are not addressed. See section 30.2.2.1 for a discussion of the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. Additional material on documentation appears in the various clinical scenarios that are presented throughout these level of care guidelines.

Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care. Eligibility for SNF Medicare Part A coverage has not changed with the inception of PPS. However, the skilled criteria and the medical review process have changed slightly. For Medicare to render payment for skilled services provided to a beneficiary during a SNF Part A stay, the facility must complete an **MDS (Minimum Data Set)**.

A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nurse specialist (CNS) or, effective with items and services furnished on or after January 1, 2011, a physician assistant (PA)) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

In this context, the definition of a “direct employment relationship” is set forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under the regulations at 42 CFR 424.20(e)(2)(ii), when a physician extender has a direct employment relationship with an entity other than the facility, and the employing entity has an agreement with the facility that includes the provision of general nursing services under the regulations at 42 CFR 409.21, an “indirect employment relationship” exists between the physician extender and the facility. By contrast, such an indirect employment relationship does not exist if the agreement between the facility and the physician extender’s employer solely involves the performance of delegated physician tasks under the regulations at 42 CFR 483.40(e).

Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services. Payment may be based on reasonable cost or be under the SNF Prospective Payment System (see §10). The facility may charge the beneficiary for services they request that are not included in the PPS rate or otherwise covered by Medicare (i.e., extra meals for family members).

An inpatient is a person who has been admitted to a skilled nursing facility or swing bed hospital for bed occupancy for purposes of receiving inpatient services. A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged and do not actually use a bed overnight.

Covered Services in a Skilled Nursing Facility

Physical Therapy, Speech-Language Pathology, and Occupational Therapy

These rehabilitation services are furnished by the Skilled Nursing Facility or by others under arrangements with the facility and under its supervision. These **types of extended care Medicare covers** are vital for recovery and maintaining function. For Speech-Language Pathology, see Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §100. For Occupational Therapy, see Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §90.

Examples of conditions that might necessitate such skilled rehabilitation services in an SNF setting include recovery from a stroke, hip fracture, major surgery, or exacerbations of chronic conditions like Parkinson’s disease, where intensive, daily therapy is required to regain mobility, speech, or daily living skills. These services must be provided by the SNF or by others under arrangements with the SNF for beneficiaries in either a covered Part A stay or a non-covered stay in the SNF. Bundling to the SNF is not required for beneficiaries residing in a non-certified portion of a facility containing a distinct part SNF if the facility as whole is not primarily engaged in the provision of skilled care.

Drugs and Biologicals

Drugs and biologicals for use in the facility, which are ordinarily furnished by the facility for the care and treatment of inpatients, are covered. Such drugs and biologicals are not limited to those routinely stocked by the skilled nursing facility but include those obtained for the patient from an outside source, such as a pharmacy in the community. Drugs and biologicals are included in the SNF PPS except for those Part B drugs specifically excluded. Since the provision of drugs and biologicals is considered an essential part of skilled nursing care, a facility must assure their availability to inpatients in order to be found capable of furnishing the level of care required for participation in the program. When a facility secures drugs and biologicals from an outside source, their availability is assured only if the facility assumes financial responsibility for the necessary drugs and biologicals, i.e., the supplier looks to the facility, not the patient, for payment.

Other Services

The use of an operating room and any special equipment, supplies, or services would not constitute covered extended care services except when furnished to the facility by a hospital with which the facility has a transfer agreement, since operating rooms are not generally maintained by skilled nursing facilities. However, supplies and nursing services connected with minor surgery performed in a skilled nursing facility that does not require the use of an operating room or any special equipment or supplies associated with such a room would be covered extended care services and paid as part of inpatient SNF PPS.

Key Takeaways on Medicare SNF Extended Care

• Extended care services in a Skilled Nursing Facility (SNF) are covered under **Medicare Part A** for eligible inpatients requiring skilled nursing or rehabilitation.
• Eligibility hinges on four core factors: the need for daily skilled services, physician orders, the inability to receive care outside an inpatient SNF setting, and the medical necessity of the services.
• Covered services include nursing care, therapies (physical, occupational, speech-language pathology), medical social services, drugs, supplies, and certain medical services.
• A physician or qualified physician extender must sign a certification or recertification statement to validate the need for SNF care.
• Always consult the latest **CMS guidelines for SNF services** for the most up-to-date information on coverage and eligibility, as regulations are subject to change.