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Ask Ms. Medicare

A Right to Know If Medicare Won't Cover Your Skilled Nursing Care

Q. My father-in-law spent two days in the hospital and was then sent to a skilled nursing facility for rehab. Now the facility has billed my mother-in-law, and not Medicare, for the full cost of his care. The hospital did not tell them that Medicare wouldn’t pay. What can we do?

The rules on Medicare coverage for skilled nursing facility (SNF) care are very strict. You must be admitted as a patient to a hospital for three full days consecutively before qualifying for skilled nursing care that Medicare will pay for.

A hospital that refers someone to a skilled nursing facility when the three-day condition is not met is required to inform the patient, in a specific notice, that Medicare will not cover the cost. And the nursing facility is also required to give the same information to an incoming patient.

In this situation, your in-laws should appeal to the quality improvement organization (QIO) in their region, the agency Medicare uses to assess complaints against hospitals and other facilities. If it finds that the hospital (or the skilled nursing facility) was in error, your in-laws will not have to pay the nursing bill. While your appeal is pending, the nursing facility cannot insist that you pay.

To find the phone number and Web address of your regional QIO, go to the “Find Helpful Contacts for Organizations” section of Medicare’s website. Search for a “specific organization” and enter the name of your state.

For information on other rules required to qualify for SNF care, see the official publication “Medicare Coverage of Skilled Nursing Facility Care.”

Patricia Barry is a senior editor at the AARP Bulletin.

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