What you should know before you read this booklet

It’s important to know how you get your Medicare coverage. Most people with Medicare get their coverage through Original Medicare. The information in this booklet explains skilled nursing facility (SNF) coverage in Original Medicare.

If you get your health care from a Medicare Advantage Plan or other Medicare health plan, you have at least the same coverage as people with Original Medicare. Special notes throughout this booklet explain how your SNF benefits, choice of facility, costs, coverage, and/or rights and protections may be different in a Medicare Advantage Plan. Read your plan materials or check with your plan for specific information.

“Medicare Coverage of Skilled Nursing Facility Care” is prepared by the Centers for Medicare & Medicaid Services (CMS). CMS and states oversee the quality of skilled nursing facilities (SNFs). State agencies make certification recommendations to CMS. CMS is responsible for certifying SNFs.

“Medicare Coverage of Skilled Nursing Facility Care” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048.

This product was produced at U.S. taxpayer expense.

Table of Contents

Section 1: The Basics

What’s skilled nursing facility (SNF) care?

Why would I need skilled nursing or skilled therapy care?

How do I find a SNF?

Section 2: Medicare SNF Coverage

Will Medicare cover SNF care?

How long does Medicare cover SNF care?

Examples of Medicare SNF coverage

What does Medicare cover when I qualify for SNF care?

Section 3: What You Pay

What do I pay for SNF care in 2023?

Can I get help with costs?

Section 4: Your Care in a SNF

What’s an assessment?

What’s a care plan?

Section 5: When Your SNF Coverage Ends

What if I think my SNF coverage is ending too soon?

Section 6: Your Rights & Protections

What are my rights in a SNF?

How can I report and resolve problems?

What if I think my SNF charges are wrong?

Section 7: Skilled Nursing Facility Checklist

Section 8: Definitions

Section 1: The Basics

Highlighted words are defined here.

What’s skilled nursing facility (SNF) care?

SNFs provide high quality medical care from skilled nursing or therapy staff to treat, manage, and observe your condition, and evaluate your care. Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, skilled nursing or therapy professionals. These professionals may be:

- Doctors

- Registered nurses

- Licensed practical and vocational nurses

- Physical and occupational therapists

- Speech-language pathologists

- Audiologists

Examples of SNF care include physical therapy and intravenous injections given by a registered nurse or doctor. Keep in mind SNF care is different from custodial care. Custodial care helps you with daily activities, like bathing and dressing. It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters. Custodial care is often given in a nursing facility. Go here to read about ways to get help paying for custodial care.

When and how long does Medicare cover care in a SNF?

SNF care is generally provided daily, on a short-term basis. Medicare covers up to 100 days of care in a SNF, in a single benefit period, as long as you stay eligible. Go here for more details.

What’s covered by Original Medicare?

- For days 1–20, Medicare pays the full cost for covered services. You pay nothing.

- For days 21–100, Medicare pays all but a daily coinsurance for covered services. You pay a daily coinsurance.

- For days beyond 100, Medicare pays nothing. You pay the full cost for covered services.

The coinsurance is up to $200 per day in 2023. It can change each year. If you have a Medicare Supplement Insurance (Medigap) policy with Original Medicare or have a Medicare Advantage Plan, your costs may be different, or you may have more coverage.

Why would I need skilled nursing or skilled therapy care?

You may get skilled nursing care when it’s necessary to:

- Help improve your condition.

- Maintain your current condition, or prevent or delay it from getting worse.

You may get skilled therapy care when it’s necessary to:

- Help improve your condition.

- Set up a maintenance program designed to maintain your current condition or prevent or delay it from getting worse.

- Perform a safe and effective maintenance program. Complications in your condition, or the complexity of services you get may sometimes require continued skilled therapy care, even after the maintenance program is set up.

Skilled care helps you get better, function more independently, and may help you manage your health.

How do I find a SNF?

Finding a SNF that’s right for you matters. Advance planning will help you choose a SNF that meets your needs and gives you the quality care you deserve.

If the hospital you’re in has its own SNF, and a bed is available, you may choose to stay there. If not, you may need to find an available bed at a separate facility.

If you have Original Medicare, you can go to any Medicare-certified SNF if a bed is available. If you have a Medicare Advantage Plan, depending on the type of plan, you:

- Can usually go to any Medicare-certified SNF if a bed is available, but it may be less expensive to go to a SNF that’s in your plan’s network. Some plans require you to get your SNF care from a SNF in your plan’s network. Call your plan to see which SNFs are in your plan’s network. If you meet certain conditions, you may be able to get your SNF care from a SNF that isn’t in your plan’s network.

- May need to let the plan know you need SNF care before you’re admitted to the SNF. You may have to pay for more (or all) of your SNF care if you don’t tell your plan before you’re admitted.

To choose a SNF:

1. Find out about the SNFs in your area.

2. Find out how SNFs compare in quality of care. Go here.

3. Visit the SNFs you’re interested in, or have someone visit for you. Go here.

4. Choose the SNF that best meets your needs. Use the information here as a guide.

Step 1: Find out about the SNFs in your area

- Visit Medicare.gov/care-compare to find a list of all of the Medicare- and Medicaid-certified SNFs in your area and general information about every Medicare- and Medicaid-certified SNF in the country. You can also get information about the quality of care provided by each SNF. If you don’t have a computer, smart phone, or tablet, your local library or senior center may be able to help you.

- If you’re in the hospital, ask the hospital’s discharge planner or social worker for a list of local SNFs. They may help you find an available bed.

- Visit or call your local social service agency or hospital. Ask to speak to a social worker or case manager who can help you find a SNF in your area.

- Ask people you trust, like your doctor, family, friends, or neighbors if they have had personal experience with SNFs. They may be able to give you the name of a SNF with which they had a good experience.

- Call your Area Agency on Aging for information about the SNFs in your area. You can get the phone number of your local Area Agency on Aging by visiting eldercare.acl.gov or calling the Eldercare Locator at 1-800-677-1116.

Step 2: Find out how SNFs compare in quality of care

Quality of care means doing the right thing, at the right time, in the right way, for the right person, and having the best possible results. Medicare certifies SNFs, to make sure SNFs meet specific federal health and safety requirements. To find out how SNFs in your area compare in quality, visit Medicare.gov/care-compare. You can compare the health inspection survey reports of the SNFs in your area and look at other information, like staffing levels and quality measure results. You can also compare the star rating results for each SNF.

Other ways to find out about SNF quality of care:

- Call the local office of consumer affairs for your state. Ask if they have information on the quality of SNFs.

- Call your state health department. Ask if they have information on the quality of SNFs.

- Call your Long-Term Care Ombudsman. The Ombudsman program helps residents of SNFs solve problems by acting on their behalf. Ombudsmen visit SNFs and speak with residents throughout the year to make sure residents’ rights are protected. They’re a good source of general information about SNFs and can work to solve problems with your care, including financial issues. They may be able to help you compare the SNF’s strengths and weaknesses. Ask them questions like: how many complaints they’ve gotten about a SNF, what kind of complaints they were, and if the problems were resolved.

Step 3: Visit the SNFs you’re interested in, or have someone visit for you

If you’re able to do so, visit the SNFs that interest you before you make a decision. A visit gives you the chance to see the residents, staff, and facility. It also allows you to talk with SNF staff and with the people who reside and get care at the SNF and their family members. Call and make an appointment to tour the SNF before you visit.

If you can’t visit the SNF yourself, you may want to ask a family member or friend to visit for you.

Note: Many SNFs have implemented health and safety measures to protect you and other residents from COVID-19 during the public health emergency. Be sure to follow this guidance when you visit.

Ask the staff at the facility to:

- Show you the information they’re required to post in the facility, like the number of licensed and unlicensed nursing staff.

- Show you the results of the most recent SNF health inspection survey report. They must have it available for you to look at upon request. If the SNF was cited for any non-compliance, ask if the issues have been corrected and to see the correction plan.

- Explain to you about anything you see and hear that you don’t understand. For example, a person may be shouting or making unrecognizable noises. It may be because he or she is confused, not because they’re being hurt or neglected.

- Explain the quality information from Medicare.gov/care-compare.

Go to a resident/family council meeting

Ask a SNF staff member if you can get permission from the residents or residents’ families to attend a meeting of their resident council and/or family meeting. These councils are usually organized and managed by the residents’ families to improve the quality of care and life for the residents, and to address concerns.

Step 4: Choose the SNF that best meets your needs.

Use the “Skilled Nursing Facility Checklist” here. If you find more than one facility with a bed available, use all the information you get to compare them. Once you’ve made your decision, you can make your arrangements with the SNF.

Section 2: Medicare SNF Coverage

Highlighted words are defined here.

Will Medicare cover SNF care?

Medicare will cover SNF care only if all of these are true:

1. You have Medicare Part A (Hospital Insurance) and have days left in your benefit period available to use. Go here to learn about benefit periods.

2. You have a qualifying hospital stay. This means a prior medically necessary inpatient hospital stay of 3 consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital. Time you spend at the hospital under observation or in the emergency room before you’re admitted doesn’t count toward the 3-day qualifying inpatient hospital stay, even if you’re there overnight. You must enter the SNF within a short time (generally 30 days) of leaving the hospital.

After you leave the SNF, if you re-enter the same or another SNF within 30 days, you may not need another qualifying 3-day inpatient hospital stay to get additional SNF benefits. This is also true if you stop getting skilled care while in the SNF and then start getting skilled care again within 30 days. If you’re in a Medicare Advantage Plan, you might not need to be in the hospital for 3 consecutive days. Check with your plan about costs for a SNF stay.

3. You need, and your doctor has ordered, inpatient services in a SNF, which require the skills of professional personnel (like doctors, registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, or audiologists) and are given by, or under the supervision of, these skilled personnel.

4. You need and get the required skilled care on a daily basis and the services, as a practical matter, can only be given when you’re an inpatient in a SNF. If you’re in a SNF for skilled therapy services only, your care is considered daily care if the therapy services are needed and given just 5–7 days a week.

5. You need these skilled services for one of these:

- An ongoing condition that was also treated during your qualifying 3-day inpatient hospital stay, (even if it wasn’t the reason you were admitted to the hospital).

- A new condition that started while you were getting SNF care for the ongoing condition. For example, if you’re in a SNF because you broke your hip and you then have a stroke, Medicare may cover therapy services for the stroke, even if you no longer need therapy for your hip.

6. The skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.

7. You get these skilled services in a Medicare-certified SNF.

How long does Medicare cover SNF care?

Medicare uses a period of time called a benefit period to keep track of how many days of SNF benefits you use, and how many are still available. A benefit period begins on the day you start getting inpatient hospital or SNF care. You can get up to 100 days of SNF coverage in a benefit period. Once you use those 100 days, your current benefit period must end before you can renew your SNF benefits.

Your benefit period ends:

- When you haven’t been in a SNF or a hospital for at least 60 days in a row.

- If you remain in a SNF, when you haven’t gotten skilled care there for at least 60 days in a row.

There’s no limit to the number of benefit periods you can have. However, once a benefit period ends, you must have another 3-day qualifying hospital stay and meet these Medicare requirements before you can get up to another 100 days of SNF benefits.

What if I stop getting skilled care in the SNF, or leave altogether? How does this affect Medicare coverage if I need more skilled care in a SNF later on?

This depends on how long your break in SNF care lasts.

If your break in SNF care lasts for less than 30 days:

- You don’t need a new 3-day inpatient hospital stay to qualify for coverage of additional SNF care, but you need to meet all other coverage requirements. Go to item 2 here for more information.

- Your current benefit period would continue. This means that the maximum coverage available would be the number of unused SNF benefit days remaining in your current benefit period.

If your break in SNF care lasts at least 30 but less than 60 days:

- Medicare won’t cover additional SNF care unless you have a new 3-day qualifying inpatient hospital stay, and you meet all other coverage requirements. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

- Your current benefit period would continue. This means that the maximum coverage available would be the number of unused SNF benefit days remaining in your current benefit period.

If your break in SNF care lasts at least 60 days:

- Medicare won’t cover additional SNF care unless you have a new 3-day qualifying inpatient hospital stay and all other coverage requirements are met. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

- Your current benefit period would end and your SNF benefits would be renewed. This means that the maximum coverage available would be up to 100 days of SNF benefits in your new benefit period.

Examples of Medicare SNF coverage

In these 3 examples, assume the patients met all the qualifications for Medicare coverage of SNF care listed here, including the 3-day qualifying inpatient hospital stay. They’re then admitted to a SNF because they need skilled care, and are discharged from the SNF before their benefit period ends.

Example 1: Out of the SNF for less than 30 days

Mrs. Perkins got 10 days of Medicare-covered SNF care after she was hospitalized when she broke her leg. Her Medicare-covered SNF care ended when she stopped needing skilled care. She chose to go home rather than pay for custodial care. After 10 days, her doctor decided she needed more skilled care for her broken leg and she was readmitted to the SNF. Medicare will cover this SNF stay. She has 90 days of coverage left in her benefit period.

Example 2: Out of the SNF for at least 30 but less than 60 days

Mr. Jones got 20 days of Medicare-covered SNF care after he was hospitalized when he had a stroke. His Medicare-covered SNF care ended when he stopped needing skilled care. He chose to stay in the SNF and pay for 2 days of custodial care. He then went home. After 34 days, his doctor readmitted him to the hospital for 4 more days because of his stroke. He was then admitted to a SNF because he needed skilled care. Even though Mr. Jones was out of the SNF for more than 30 days, Medicare will cover this SNF stay because he had a new 3-day qualifying inpatient hospital stay. He has 80 days of coverage left in this benefit period.

Example 3: Out of the SNF for at least 60 days

Mrs. Smith got 20 days of Medicare-covered SNF care after she was hospitalized when she had back surgery. Her Medicare-covered SNF care ended when she no longer needed skilled care. She chose to go home rather than pay for custodial care. After 65 days, she was hospitalized for 3 days due to a fall. She was then admitted to a SNF because she needed skilled care. Since she was out of the SNF for more than 60 days, her benefit period ended. Her new 3-day qualifying inpatient hospital stay starts a new benefit period. Medicare will cover up to 100 days of SNF care in this new benefit period.

If I’m in a SNF but must be readmitted to the hospital, will the SNF hold my bed for me?

For some Medicare-Medicaid patients in some states, a bed may be available for you at the same facility if you need more skilled care after your hospital stay. However, depending on the state and your eligibility for Medicaid, you may have to go to another SNF if a bed isn’t available. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there is a cost to hold the bed for you and what that cost is.

Note: Go here for information about what happens when your SNF coverage ends.

What does Medicare cover when I qualify for SNF care?

Medicare covers:

- A semi-private room (a room you share with other patients)

- Meals

- Skilled nursing care

- Medical social services

- Medications

- Medical supplies and equipment used in the facility

- Ambulance transportation (when other transportation would endanger your health) to the nearest supplier of medically-necessary services that aren’t available at the SNF, including the return trip

- Dietary counseling

Medicare covers physical therapy, occupational therapy, and speech language pathology services if they’re needed to meet your health goal. A health goal is the expected result of your treatment, like being able to walk a certain distance or to climb stairs.

Section 3: What You Pay

Highlighted words are defined here.

What do I pay for SNF care in 2023?

In Original Medicare, for each benefit period, you pay:

- For days 1–20: You pay nothing for covered services. Medicare pays the full cost.

- For days 21–100: You pay up to $200 per day for covered services. Medicare pays all but the daily coinsurance.

- For days beyond 100: You pay the full cost for services. Medicare pays nothing.

You must also pay all additional charges not covered by Medicare (like phone charges and laundry fees).

Note: Your SNF costs may be different if you’re in a Medicare Advantage Plan. Check with your plan.

Can I get help with costs?

Help from your state: If your income and resources are limited, you may be able to get help to pay for SNF care, custodial care, or other health care costs. If you qualify for both Medicare and Medicaid, most health care costs may be covered. You may also qualify for the Medicaid nursing home benefit or the Programs of All-inclusive Care for the Elderly (PACE). Call your State Medical Assistance (Medicaid) office for more information. To find the number, visit Medicare.gov/talk-to-someone.

Employer or union coverage: If you have health coverage from an employer or union, check with your benefits administrator to see what’s covered.

Medigap policy: If you have Original Medicare, you may also have a Medicare Supplement Insurance (Medigap) policy to fill gaps in your coverage. Some Medigap policies pay all or some of the SNF coinsurance for days 21–100. Check with your policy or call the insurance company to find out if your policy provides coverage for the Medicare SNF coinsurance.

For more information about Medigap policies, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Long-term care insurance: If you have long-term care insurance, check your policy or call the insurance company to find out if skilled or custodial care is covered.

For more information about help paying for health care, call your local State Health Insurance Assistance Program (SHIP). To find the phone number, visit Medicare.gov/talk-to-someone.

Section 4: Your Care in a SNF

Highlighted words are defined here.

The care you get in a SNF is based on the care plan that staff develop, based on your assessments.

What’s an assessment?

When you go to a SNF, a team of staff from different medical fields (depending on your health needs) plans your care. Your SNF care is based on your doctor’s orders and information the team gathers when they do daily assessments of your condition. Your doctor and the SNF staff (with your input) use the assessments to decide what services you need and your health goal (or goals).

Medicare requires an initial assessment within the first 8 days of SNF care. The SNF uses this assessment to plan and manage your care, and Medicare uses it to determine appropriate payment to the SNF. The SNF must also record any other assessments during your stay that it determines are necessary to account for significant changes in your condition.

An assessment includes gathering information about:

- Your current physical and mental condition

- Your medical history

- Medications you’re taking

- How well you can do activities of daily living, like bathing, dressing, eating, getting in and out of bed or a chair, moving around, and using the bathroom

- Your speech

- Your decision-making ability

- Physical limitations, like problems with your hearing or vision, paralysis after a stroke, or balance problems

What’s a care plan?

When your health condition is assessed, SNF staff prepare or update your care plan. You (if you’re able), or your family, or someone acting on your behalf, have the right to take part in planning your care with the SNF staff. Let the staff know if you want to take part. This helps keep you aware of how the care you get will help you reach your health care goals.

Your care plan may include:

- What kind of services you need

- What type of health care professional should give you the services

- How often and for how long you’ll need the services

- What kind of equipment or supplies you need, like a wheelchair or feeding tube

- Your special diet, if you need one

- Your health goal (or goals), and how your care plan will help you reach it

Your Medicare coverage continues when all of these apply:

- You’ve used less than 100 days of coverage in this benefit period

- You still need inpatient skilled care every day

- The skilled services you get are reasonable and necessary for your condition

Your Medicare coverage ends if any of these apply:

- You’ve used all 100 days of coverage in the benefit period

- You no longer need inpatient skilled care every day

- The skilled care you get is no longer reasonable and necessary for your condition

Note: If you refuse your daily skilled nursing or therapy care, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care for a day or two (for instance, if you get the flu), you may be able to continue to get Medicare coverage temporarily.

Section 5: When Your SNF Coverage Ends

Highlighted words are defined here.

What if I think my SNF coverage is ending too soon?

When Medicare coverage of your SNF stay is ending because it’s no longer medically reasonable and necessary or is considered custodial care, you’ll get a written notice from your provider called the “Notice of Medicare Non-Coverage” (NOMNC).

If you’re getting Medicare-covered services from a SNF, and you think your Medicare-covered SNF services are ending too soon, you can ask for a fast appeal. Your NOMNC will tell you how to ask for a fast appeal. (The notice might call it an “immediate” or “expedited” appeal.) If you don’t get this notice, ask your provider for it.

With a fast appeal, an independent reviewer called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) will decide if your services need to continue.

- It’s important to call your BFCC-QIO to request a fast appeal no later than the time shown on the notice you get from your provider. Use the phone number for your BFCC-QIO listed on your notice to request your appeal.

- Ask your doctor or other health care provider to submit any information to the BFCC-QIO that may help your case.

- If you miss the deadline, you may still have appeal rights:

- If you have Original Medicare, call your BFCC-QIO.

- If you’re in a Medicare health plan, call your plan or your BFCC-QIO.

When Medicare coverage of your SNF stay is ending because you have no benefit days remaining, the SNF may give you a notice. However, written notice isn’t required to charge you when you no longer have benefit days and remain in the facility, so it’s important that you or your family keep track of the number of benefit days you have remaining.

When Medicare coverage of your SNF stay is ending because continued care isn’t medically reasonable and necessary or is considered custodial and you choose to remain in the SNF, you may have to pay for SNF charges. If you have Original Medicare, the SNF must issue the “Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage” (SNFABN) or a SNF denial letter to transfer financial liability to you.

This notice tells you:

- The date your Medicare coverage will end (and you must start to pay)

- Why your stay isn’t (or is no longer) covered

- The estimated cost of the noncovered care

- Your right to request that the SNF submit a claim to Medicare so you can get an official payment decision from Medicare—this type of claim is sometimes called a “demand bill”

- If you request to have a claim submitted, you aren’t required to pay (any coinsurance and services and supplies Medicare doesn’t cover) for your SNF stay until you’re informed of Medicare’s decision if Medicare determines you didn’t meet Medicare’s criteria, you’ll pay for the cost of the stay

- Where you (or someone acting on your behalf) should sign to show you got the notice

You can choose to pay for skilled care yourself when your SNF care coverage ends. Check with the SNF to see how much it costs. Go here for information on ways you can get help to pay skilled and custodial nursing care costs.

Note: If you’re in a Medicare Advantage Plan or other Medicare health plan, check with your plan to find out how they’ll let you know your Medicare coverage is ending when you no longer have benefit days. You can ask your plan for prior authorization of your stay.

If you don’t agree with your plan’s decision, you can then file an appeal. Read about how to file an appeal here.

It’s important to plan ahead

When you leave the SNF, you may need help with grocery shopping, bathing, dressing, or transportation. Or, you may need to think about home health care.

If you need custodial care in a nursing facility after you’re discharged from the SNF, you may want to start thinking about where you want to go. If the SNF you’re in has a bed available, and you’re happy with the care you have had so far, you may want to stay there.

Remember, Medicare doesn’t cover custodial care if it’s the only kind of care you need.

Section 6: Your Rights & Protections

Highlighted words are defined here.

What are my rights in a SNF?

Federal law specifies that a SNF resident’s rights include:

- Freedom from discrimination—SNFs don’t have to accept all applicants, but they must comply with laws that don’t allow discrimination based on race, color, national origin, disability, age, diagnosis, severity of your condition, payment source, or religion under certain conditions. If you believe you’ve been discriminated against, call the Department of Health & Human Services, Office for Civil Rights at 1-800-368-1019. TTY users can call 1-800-587-7697.

- Respect—You have the right to be treated with dignity and respect. You have the right to make your own schedule, including when you go to bed, rise in the morning, and eat your meals, as long as it fits your care plan. You have the right to choose the activities you want to go to.

- Freedom from abuse and neglect—You have the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, and misappropriation of your property by anyone. This includes, but isn’t limited to SNF staff, other residents, consultants, volunteers, staff from other agencies, family members or legal guardians, friends, or other individuals.

If you feel you’ve been abused or neglected (your needs were not met), report this to the SNF, your family, your local Long-Term Care Ombudsman, or your State Survey Agency. It may be appropriate to report the incident of abuse to local law enforcement and the Medicaid Fraud Control Unit (their phone numbers should be posted in the SNF).

- Freedom from restraints —Physical restraints are any manual method, or physical or mechanical device, material, or equipment attached to or near your body so that you can’t remove the restraint easily. Physical restraints prevent freedom of movement or normal access to one’s own body. A chemical restraint is a drug that’s used for discipline or convenience and isn’t needed to treat your medical symptoms.

It’s against the law for a SNF to use physical or chemical restraints, unless it’s necessary to treat your medical symptoms. Restraints can’t be used to punish or for the convenience of the SNF staff. You have the right to refuse restraint use except if you’re at risk of harming yourself or others.

- Information on services and fees —You must be informed in writing about services and fees before you move into the SNF. The SNF can’t require a minimum entrance fee as a condition of residence. You can’t be charged by the SNF for items or services that you didn’t request, and you can’t be required to request extra services as a condition of continued stay at the SNF.

- Money —You have the right to manage your own money or to choose someone you trust to do this for you. If you ask the SNF to manage your personal funds, you must sign a written statement that allows the SNF to do this for you. However, the SNF must allow you access to your bank accounts, cash, and other financial records. Your money (over $50 if you have Medicaid and over $100 if you have Medicare) must be placed by the SNF in an account that will provide interest. They must give you quarterly statements. The SNF must protect your funds from any loss by buying a bond or providing other similar protections.

- Privacy, property, and living arrangements —You have the right to privacy, and to keep and use your personal belongings and property as long as they don’t interfere with the rights, health, or safety of others. SNF staff should never open your mail unless you allow it. You have the right to use a phone and talk privately. The SNF must protect your property from theft. This may include using a safe in the facility or having cabinets with locked doors in resident rooms. If you and your spouse live in the same SNF, you’re entitled to share a room (if you both agree to do so).

- Medical care—You have the right to be informed about your medical condition, medications, and to see your own doctor. You also have the right to refuse medications and treatments (but this could be harmful to your health). You have the right to take part in developing your care plan. Care plans are explained here. You have the right to look at your medical records and reports when you ask.

- Visitors —You have the right to spend private time with visitors at any reasonable hour. The SNF must permit your family to visit you at any time, as long as you wish to see them. You don’t have to see any visitor you don’t wish to see. Any person who gives you help with your health or legal services may see you at any reasonable time. This includes your doctor, representative from the health department, and your Long-Term Care Ombudsman, among others.

- Social services —The SNF must provide you with any needed medically-related social services, including counseling, help solving problems with other residents, help in contacting legal and financial professionals, and discharge planning.

- Complaints—You have the right to make a complaint to the staff of the SNF, or any other person, without fear of punishment. The SNF must resolve the issue promptly. Read “How can I report and resolve problems?” on the next page.

- Protection against unfair transfer or discharge—You can’t be sent to another SNF, or made to leave the SNF unless:

- It’s necessary for the welfare, health, or safety of you or others

- Your health has declined to the point that the SNF can’t meet your care needs

- Your health has improved to the point that SNF care is no longer necessary

- You don’t pay for the services you’re responsible for

- The SNF closes

A SNF can’t make you leave if you’re waiting to get Medicaid. The SNF should work with other state agencies to get payment if a family member or other person is holding your money.

- Involvement of your family and friends—Family members and legal guardians may meet with the families of other residents and may participate in family councils.

By law, SNFs must develop a care plan for each resident. Care plans are explained here. You have the right to take part in this process, and family members can help with your care plan with your permission. If your relative is your legal guardian, he or she has the right to look at all medical records about you and has the right to make important decisions on your behalf.

Family and friends can help make sure you get good quality care. They can visit and get to know the staff and the SNF’s rules.

How can I report and resolve problems?

If you have a problem at the SNF, talk to the staff. For example, if you have a problem with your care, talk to the nurse or Certified Nurse Assistant (CNA). The staff may not know there’s a problem unless you tell them. If the problem isn’t resolved, ask to talk with the supervisor, the social worker, the Director of Nursing, or your doctor.

The facility must have a procedure for complaints. If your problem isn’t resolved, follow the facility’s procedure for complaints. You may also want to bring the problem to the resident or family council.

The SNF must post the name, address, and phone number of state groups, like the State Survey Agency, the State Licensure Office, the State Ombudsman Program, the Protection and Advocacy Network, and the Medicaid Fraud Control Unit.

If you feel you need outside help to resolve your problem, call the Long-Term Care Ombudsman or the State Survey Agency for your state.

What if I think my SNF charges are wrong?

If you have Original Medicare, you’ll get a “Medicare Summary Notice” (MSN) from a company that handles Medicare bills for all your SNF charges. If you think these charges are wrong, call the phone number on the notice for the company that sent the notice to you.

Note: If you’re in a Medicare Advantage Plan, call your plan if you have questions about your bills.

Section 7: Skilled Nursing Facility Checklist

Highlighted words are defined here.

Use this completed checklist and the quality of care information from Medicare.gov to help you compare the SNFs you’re interested in. You can find this information by visiting Medicare.gov/care-compare.

Medicare.gov/care-compare includes information like:

- The number of beds at the facility, and how many are being used (occupied)

- Nursing staff hours per resident per day

- SNF health inspection summary results

- Who owns and manages the SNF

- Noncompliance deficiency and complaint information

- Quality measures for each SNF

If you don’t have a smart phone or computer, your local library or senior center may be able to help you find this information. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Name of skilled nursing facility (SNF):

Date of visit:

Yes

No

Comments

Basic information

The SNF is Medicare and Medicaid certified.

The SNF provides the type of skilled care you need, and a bed is available.

The SNF offers special services in a separate unit (like dementia, ventilator, or therapy).

The SNF is located close enough for friends and family to visit.

Resident appearance

Residents are clean, appropriately dressed for the season or time of day, and well groomed.

Living spaces

The SNF is clean.

The temperature, noise levels, and lighting in the SNF are comfortable.

Yes

No

Comments

Staff

The relationship between the staff and the residents appears to be warm, polite, and respectful.

All staff wear name tags.

The SNF offers a training and continuing education program for all staff.

The SNF does background checks on all staff.

There’s a full-time Registered Nurse (RN) in the SNF at all times, other than the Administrator or Director of Nursing.

The same team of nurses and Certified Nursing Assistants (CNAs) work with the same reasonable number of residents 4–5 days per week.

CNAs are involved in care planning meetings.

There’s a full-time social worker on staff.

There’s a licensed doctor on staff , in the facility daily, and reachable at all times.

Yes

No

Comments

Residents’ rooms

Residents may have personal belongings and/or furniture in their rooms, and there are policies to protect their possessions.

Each resident has a window, phone, television, and easy access to water in his or her bedroom.

Residents have a choice of roommates.

Hallways, stairs, lounges, & bathrooms

There are quiet areas where residents can visit with friends and family.

The SNF has smoke detectors, sprinklers, and clearly marked exits.

All common areas, resident rooms, and doorways are designed for wheelchair use.

There are handrails in the hallways and grab bars in the bathroom.

Yes

No

Comments

Menus & food

Residents have a choice of food items at each meal. (Ask if your favorite foods are served.)

Nutritious snacks are available upon request.

Staff help residents eat and drink at mealtimes if help is needed.

Activities

Residents, including those who are unable to leave their rooms, may choose to take part in a variety of activities.

The SNF has outdoor areas for resident use, and staff help residents go outside.

Safety & care

The SNF has an emergency evacuation plan and holds regular fire drills.

Residents get preventive care, like a yearly flu shot, to help keep them healthy.

Residents may still see their regular doctors.

The SNF has an arrangement with a nearby hospital for emergencies.

Care plan meetings are held with residents and family members at times that are convenient whenever possible.

The SNF has corrected all deficiencies (failure to meet one or more federal or state requirements) on its last health inspection survey report.

Section 8: Definitions

Appeal—An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare drug plan. You can appeal if Medicare or your plan denies one of these:

- Your request for a health care service, supply, item, or prescription drug that you think you should be able to get

- Your request for payment for a health care service, supply, item, or prescription drug you already got

- Your request to change the amount you must pay for a health care service, supply, item or prescription drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.

Benefit period—The way that Original Medicare measures your use of hospital and SNF services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Coinsurance—An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). The daily SNF coinsurance amount for each of days 21–100 of SNF care is 1/8 of the inpatient hospital deductible for the calendar year.

Custodial care—Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

Long-term Care Ombudsman—An independent advocate (supporter) for nursing home and assisted living facility residents who works to solve problems of residents of nursing homes, assisted living facilities, or similar facilities. They may be able to provide information about home health agencies in their area.

Medicaid—A joint federal and state program that helps with medical costs for some people with limited incomes and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medicare Advantage Plan (Part C)—A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan, and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part A (Hospital Insurance)—Part A covers inpatient hospital stays, care in a SNF, hospice care, and some home health care.

Medicare Summary Notice (MSN)—A notice you get after the doctor, other health care provider, or supplier files a claim for Part A and Part B services in Original Medicare. It explains what the doctor, other health care provider, or supplier billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Medigap policy—Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.

Original Medicare—Original Medicare is a fee-for-service health plan that has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Programs of All-inclusive Care for the Elderly (PACE)—A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.

State Health Insurance Assistance Program (SHIP)—A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

State Survey Agency—A state agency that oversees health care facilities that participate in the Medicare and/or Medicaid programs by, for example, inspecting health care facilities and investigating complaints to ensure that health and safety standards are met.

CMS Accessible Communications

The Centers for Medicare & Medicaid Services (CMS) provides free auxiliary aids and services, including information in accessible formats like braille, large print, data or audio files, relay services and TTY communications. If you request information in an accessible format from CMS, you won’t be disadvantaged by any additional time necessary to provide it. This means you’ll get extra time to take any action if there’s a delay in fulfilling your request.

To request Medicare or Marketplace information in an accessible format you can:

1. Call us: For Medicare: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048.

2. Send us a fax: 1-844-530-3676.

3. Send us a letter:

Centers for Medicare & Medicaid Services

Offices of Hearings and Inquiries (OHI)

7500 Security Boulevard, Mail Stop S1-13-25

Baltimore, MD 21244-1850

Attn: Customer Accessibility Resource Staff

Your request should include your name, phone number, type of information you need (if known), and the mailing address where we should send the materials. We may contact you for additional information.

Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan, contact your plan to request its information in an accessible format. For Medicaid, contact your state or local Medicaid office.

Nondiscrimination Notice

The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by CMS directly or through a contractor or any other entity with which CMS arranges to carry out its programs and activities.

You can contact CMS in any of the ways included in this notice if you have any concerns about getting information in a format that you can use.

You may also file a complaint if you think you’ve been subjected to discrimination in a CMS program or activity, including experiencing issues with getting information in an accessible format from any Medicare Advantage Plan, Medicare drug plan, State or local Medicaid office, or Marketplace Qualified Health Plans. There are three ways to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

1. Online: hhs.gov/civil-rights/filing-a-complaint/index.html.

2. By phone: Call 1-800-368-1019. TTY users can call 1-800-537-7697.

3. In writing: Send information about your complaint to:

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official Business

Penalty for Private Use, $300

CMS Product No. 10153

December 2022

This booklet is available in Spanish. To get a free copy, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Esta publicación está disponible en Español. Para obtener una copia, llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048.