UCLA Santa Monica Medical Center

Discharge planning instructions following your orthopaedic surgery

Explanation of Medicare Coverage In A Skilled Nursing Facility (SNF) or Transitional Care Facility (TCU)

If you qualify for skilled nursing or transitional care due to hospitalization lasting at least 3 midnights in the hospital and a "skilled need", we hope that this document will help clarify the Medicare regulation regarding skilled nursing facility and TCU coverage.

"Skilled needs" include:

  • Physical Therapy
  • Speech Therapy
  • Tube Feedings
  • Occupational Therapy
  • IV Medications
  • Wound care dressings at least 2 times per day

Under Medicare Part A, Coverage works as follows:

1. The maximum covered stay under Medicare is 100 days.
2. THE 100-DAY STAY IS NOT AUTOMATICALLY GUARANTEED.
3. A Patient can remain at the skilled nursing facility with Medicare coverage as long as they have a "skilled need" such as those listed above.
4. Once there is no longer a "skilled need", Medicare insurance coverage stops.
5. As long as there is a "skilled need", Medicare pays entirely for the first 20 days.
6. After the first 20 days, if there is still a "skilled need", Medicare will pay 80% of the remainder of the stay.
7. From day 20-100, as long as there is a "skilled need" the 20% that Medicare does not pay for can be paid for by Medi-cal, supplemental insurance (such as Blue Cross, AARP), or out of pocket.
8. The typical length of stay under Medicare benefit with a "skilled need" is 1 to 2 weeks.

This coverage is different from HMO or other insurance coverage in the Skilled Nursing Home. However, they are similar. Please contact your HMO or insurance company for clarification of the differences.

For further questions, you may contact Medicare, Los Angeles at 1-800-675-2266.