Your Questions Answered

Great question!  The length of time you can stay in a skilled nursing facility (SNF) depends on several factors, including your type of insurance coverage, medical necessity, and specific policies set by Medicare, Medi-Cal, and private HMOs. Understanding these differences is essential for patients and families planning long-term care.

Medicare Coverage for Skilled Nursing Facilities

Medicare is the most common source of skilled nursing facility coverage for seniors, but it has strict limitations on the length of stay. Medicare Part A covers short-term stays in an SNF for patients who need rehabilitation or skilled nursing care after a hospital stay. Here are the key details:

Qualifying Criteria: To qualify, the patient must have spent at least three consecutive days in a hospital as an inpatient before being admitted to an SNF.

Covered Days: Medicare provides up to 100 days of SNF care per benefit period. However, the length of stay is based on medical necessity, meaning patients must show progress in their recovery and continue to need skilled nursing or therapy.

Cost Breakdown:

• Days 1-20: Medicare covers 100% of the costs.
• Days 21-100: The patient is responsible for a daily copayment (which changes annually; in 2025, it is estimated to be around $204 per day).
• After Day 100: Medicare coverage ends, and the patient must pay out of pocket or have another form of insurance, such as Medi-Cal or a private plan, to continue care.

Most Medicare beneficiaries do not receive the full 100 days of SNF care because coverage ends when they no longer meet Medicare’s criteria for skilled care.

HMO and Medicare Advantage Plans (Medicare Part C)

Medicare Advantage plans (HMOs and PPOs) operate differently from Original Medicare. These plans, offered by private insurance companies, must cover at least what Medicare does, but they often have additional rules and restrictions:

Authorization Required: Most Medicare Advantage plans require prior authorization for SNF stays.

Length of Stay Limitations: HMOs often approve shorter stays than Medicare’s 100-day maximum. Patients may have to be re-evaluated frequently to determine continued eligibility.

Copayments and Costs: Costs vary by plan, and some HMOs require copayments earlier than Original Medicare does.

Patients with Medicare Advantage plans should consult their specific policy to understand their SNF benefits, including how long they can stay and what costs they may be responsible for. 

Medi-Cal (California’s Medicaid Program) and Long-Term Stays

For patients who need long-term nursing home care beyond Medicare’s 100-day limit, Medi-Cal can provide coverage, as long as they meet medical and financial eligibility requirements. Here’s how Medi-Cal works for SNF stays:

No Strict Time Limit: Unlike Medicare, Medi-Cal does not have a set maximum number of days for skilled nursing care. As long as the patient continues to require skilled nursing services and meets eligibility requirements, Medi-Cal can cover their stay indefinitely.

Financial Eligibility: Medi-Cal is needs-based, meaning patients must have limited income and assets to qualify. However, California has a “Medi-Cal Share of Cost” system, where patients with higher incomes may need to contribute to their care.

Spousal Protection: Married individuals can have certain assets and income protected so that their spouse does not become impoverished.

Medi-Cal is a crucial option for those who need long-term skilled nursing care, as it provides coverage when Medicare and HMOs no longer pay for a stay.

Out-of-Pocket Private Pay and Long-Term Care Insurance

If a patient does not qualify for Medicare, an HMO, or Medi-Cal, they will have to pay out of pocket for skilled nursing care. Costs vary widely but can range from $8,000 to $15,000 per month, depending on the facility and level of care needed.

Some individuals have long-term care insurance policies, which can help cover the cost of extended stays in an SNF. These policies vary in terms of daily benefit amounts, coverage limits, and elimination periods before benefits begin. 

Conclusion: Planning for Skilled Nursing Care

The length of time a patient can stay in a skilled nursing facility depends largely on their insurance coverage and medical needs. Medicare provides up to 100 days for short-term rehabilitation, HMOs often have stricter limits, and Medi-Cal can cover long-term stays for eligible patients. Understanding these differences is essential for making informed decisions about care and financial planning.

If you or a loved one are considering a skilled nursing facility stay, it’s important to review your insurance benefits and explore options for extended care. Consulting with a hospital discharge planner, social worker, or elder law attorney can help navigate these complex healthcare systems and ensure the best possible outcome. 

Feel free to Contact Us so that we can answer any questions you may have about your stay at a skilled nursing facility.