How Do You Qualify for a Skilled Nursing Facility?

Perhaps your doctor or social worker inside or outside of the hospital is recommending inpatient rehabilitation. One of the rehabilitation options may be a skilled nursing facility (SNF). I may often refer to Skilled Nursing Facility level of care as a SNF to keep things short.

We’ve answered the question “Does Medicare Pay for a Skilled Nursing Facility?“, but what about qualifying for a skilled nursing facility? How do you know if you qualify to receive rehabilitation at a skilled nursing facility?

There are some requirements to be able to get rehabilitation at a skilled nursing facility AND have insurance pay for it.

First, you have to have a qualifying hospital stay. This is also known as the Medicare 3 midnight rule.

Second, you have to indicate a need for rehab at a skilled nursing facility. This is often a combination of Physical Therapy, Occupational Therapy and/or Speech therapy recommendations for SNF level of rehab.

Third, you may need to have a skilled nursing need. Since a SNF offers 24/7 nursing care, having a chronic or complex nursing need will help your chances of getting approved.

Medicare’s 3 Midnight Rule

So let’s talk about this mysterious 3 Midnight Rule with Medicare. You may have heard about it. Most of my patients tell me: “I heard that I have to be in the hospital for 3 days and then they will pay for me to go to rehab”. I often have to correct them because it’s a little more complicated than that.

When you admit to the hospital you are placed in a certain medical status. You are admitted under inpatient or under observation status. These two are very different in regards to how insurance is billed and what is covered. I’ll go into more detail about the difference and what is covered in another post.

If you are admitted under observation status, you will likely remain in that status for 24-48 hours if you have traditional Medicare. At this point you are likely just getting worked up for your medical condition or illness. After that you will change to inpatient status.

Once you change over to inpatient status, the clock starts. If you have traditional/original Medicare, you will need 3 inpatient midnights to qualify for skilled nursing facility (SNF) rehab.

**NOTE: If you have a Medicare replacement/advantage plan or commercial insurance, this 3 midnight rule does NOT apply. It’s one of the benefits of having these plans. There is no requirement to stay in the hospital under inpatient or observation status for any length of time.

IMPORTANT UPDATE: Because of the Coronavirus Pandemic, CMS has temporarily waived the 3 midnight rule until further notice. This means that as of now, you do not need to have 3 midnights under inpatient status to qualify for a Skilled Nursing Facility.

I will keep this updated as we learn more about the Pandemic and it’s affect on Medicare services.

Qualifying for SNF with Physical Therapy and Occupational Therapy

Most of the time the hospital attending physician will order Physical Therapy (PT) and Occupational Therapy (OT) to evaluate your needs. Physical Therapy (PT) will evaluate your mobility needs compared to your baseline. Occupational Therapy does not evaluate your need for an occupation, despite what my patients think. Instead, Occupational Therapy (OT) evaluates your ability to complete daily tasks such as dressing, bathing, toileting, cooking etc.

These evaluations are imperative to qualifying for SNF rehab under Medicare or a Medicare Advantage/Replacement plan. PT and OT must make the recommendations for SNF in order for insurance to pay for your stay at a SNF.

There are a couple of key things that Medicare and the Medicare advantage plans look for in the PT/OT recommendations. First they look for your current physical abilities compared to your baseline. Physical Therapy will need to write in their notes that you have the ability to make progress with continued Physical Therapy.

Occupational Therapy’s notes will need to say the same thing. However, to be honest, Occupational Therapy’s notes do not typically hold as much weight as Physical Therapy’s notes. But, both are still important to get insurance to pay for SNF rehab.

Physical Therapy and Occupational Therapy will also need to write that they think SNF rehab will help get you back to your baseline. Insurance wants you to get home and back to your independence as quickly as possible.

If you have had a stroke, difficulty swallowing or a cognitive impairment, Speech Therapy (ST) may also be ordered to evaluate you. Speech Therapy (ST) evaluates your ability to communicate and any speech issues you may have. Speech Therapy may also write a recommendation for SNF rehab.

As long as you have any combination of Physical Therapy, Occupational Therapy or Speech Therapy making the recommendation for SNF rehab, you can qualify for insurance to pay for SNF.

What is a Skilled Nursing Need?

In addition to recommendations from Physical Therapy (PT), Occupational Therapy (OT) and/or Speech Therapy, you must have a skilled nursing care need. A skilled nursing need can be one or a combination of needs or services that can only be given by a Registered Nurse (RN).

Qualifications of a Skilled Nursing need:

• New or complex medications that require education given by a nurse or require a nurse to administer the medication. Example: IV (intravenous) medications, narcotics, a pain pump or new insulin needs.
• Artificial nutrition needs such as PEG tube or IV nutrition. Check out our post “A List of Medical Supplies and How You Can Get Them” for a little more detail on what these are.
• Any wounds that may need dressing changes and monitoring provided by a nurse
• A new ostomy that needs monitored and changed
• A Foley catheter or a Suprapubic catheter that needs monitored, changed or insertion by a nurse
• Any new oxygen needs or breathing issues. This can include the need for a CPAP, Bipap or Trilogy. It can also include tracheostomy care.
• If you need nursing monitoring after a major surgery, especially any heart surgery.

The Bottom Line

In order for Traditional Medicare to pay for your SNF rehab stay, you will need to meet all 3 qualifications:

1. A Qualifying hospital stay of 3 inpatient midnights
2. Recommendations from PT/OT/ST for SNF level of care
3. The need for a RN to provide skilled nursing care

If you have a Medicare replacement/advantage plan or commercial insurance you will need to meet the Qualifications above #2 and #3. Documentation of these needs will be sent to your insurance for authorization and approval to pay for Skilled Nursing Facility (SNF) rehab.