How to get admitted to a SNF?: A Comprehensive Guide

According to the Centers for Medicare & Medicaid Services (CMS), a significant percentage of Medicare recipients utilize skilled nursing facility (SNF) services for post-hospitalization recovery. Understanding how to get admitted to a SNF is a crucial step for individuals and families navigating the healthcare system after an injury, illness, or surgery. This guide breaks down the process, from qualifying for care to preparing for the transition.

Quick Summary

This guide outlines the complete process for skilled nursing facility (SNF) admission, detailing the medical and financial requirements. It explains the critical differences between short-term skilled care and long-term custodial care, clarifies Medicare and Medicaid coverage criteria, and provides a checklist of necessary documentation for a seamless transition into a SNF.

Key Points

• Qualifying Hospital Stay: For Medicare coverage, you must have an inpatient hospital stay of at least three consecutive days before SNF admission.

• Doctor's Order is Required: A physician must certify the patient needs daily skilled nursing or therapy services.

• SNF is Primarily Short-Term Rehab: Skilled nursing facilities are for temporary recovery and rehabilitation, not long-term custodial care.

• Coverage Varies by Insurance: Medicare, Medicaid, and private insurance have different coverage rules and limitations for SNF stays.

• Gather Crucial Paperwork: Be prepared with medical history, physician's orders, and insurance and financial documents.

• Discharge Planning Starts at Admission: The SNF's goal is to help patients recover and transition home; be involved in the discharge plan from the beginning.

• Choose a Medicare-Certified Facility: To ensure Medicare covers your stay, select a SNF that is certified by Medicare.

Understanding Skilled Nursing Facilities and Admission Criteria

A skilled nursing facility (SNF) provides a high level of medical care from licensed professionals, typically on a short-term, rehabilitative basis following a hospital stay. It is distinct from a nursing home, which is often a long-term residence focusing on custodial care for chronic conditions. The primary goal of a SNF is to help a patient recover and regain independence so they can return home.

Medical Requirements for SNF Admission

To be admitted to a SNF, a patient must meet specific medical criteria that demonstrate a need for daily skilled services. These are services that can only be performed by, or under the direct supervision of, a licensed health professional.

• Physician's Order: A doctor must write an order certifying that the patient needs a SNF level of care.
• Qualifying Medical Condition: The patient must have a condition requiring daily skilled care, such as wound care, IV therapy, extensive rehabilitation, or post-stroke recovery.
• Assessment of Needs: A medical team will perform a comprehensive assessment to determine the appropriate level of care. This includes evaluating physical abilities, cognitive status, and medical needs.

Financial and Insurance Requirements

How you pay for a SNF stay is a major factor in the admission process and depends on the type of insurance you have. Coverage can vary significantly between Medicare, Medicaid, and private insurance.

• Medicare (Part A): For Medicare to cover a SNF stay, the patient must have a prior qualifying inpatient hospital stay of at least three consecutive days. The SNF admission must generally occur within 30 days of the hospital discharge. Medicare covers the first 20 days in full and a portion of days 21-100, but does not cover long-term custodial care.
• Medicaid: Medicaid can cover long-term care in a SNF for individuals who meet specific income and resource requirements. The process requires a “Level of Care” assessment to certify the patient needs a nursing facility level of care.
• Private Insurance: Private health insurance may cover short-term, medically necessary stays, but coverage for long-term care is rare. It is crucial to contact your provider to understand your specific policy's terms.
• Long-Term Care Insurance: This specific type of policy is designed to cover the costs of extended care in a SNF or other facilities. Coverage and terms vary by policy.

The Step-by-Step SNF Admission Process

1. Obtain a Medical Evaluation: Your doctor or the hospital's care team will conduct an evaluation to determine if skilled nursing care is medically necessary.
2. Verify Insurance Coverage: Contact your insurance provider (or the hospital's discharge planner can assist) to confirm your eligibility and coverage benefits for a SNF stay.
3. Choose a Facility: Research Medicare-certified SNFs that can meet the patient's specific needs. Use resources like the Medicare.gov Nursing Home Compare tool. Consider location, facility ratings, and available services.
4. Gather Paperwork: Collect all required documents, including medical history, insurance information, physician orders, and financial records.
5. Submit Applications: The facility's admissions coordinator will review the patient's information to determine if they can accept the case. You may need to apply to several facilities.
6. Complete Admission Paperwork: Once a facility accepts the patient, complete all necessary admission paperwork, which includes legal consents and financial disclosures.
7. Coordinate Transportation: Schedule transportation to the SNF. In some cases, Medicare may cover ambulance transport if the patient's condition necessitates it.

Short-Term Rehabilitation vs. Long-Term Placement

Feature	Short-Term Rehabilitation (SNF)	Long-Term Care (SNF or Nursing Home)
Primary Goal	Recovery and rehabilitation to return home.	Ongoing support for chronic conditions or disabilities.
Typical Duration	A few days to several weeks or months.	Indefinite or extended period.
Funding Source	Often covered by Medicare Part A (limited duration) or private insurance.	Typically covered by Medicaid or long-term care insurance; Medicare does not cover.
Level of Care	Intensive skilled nursing and therapy services.	Custodial care and assistance with daily living activities.
Admission Trigger	A qualifying hospital stay of at least three days.	A physician-certified need for long-term skilled supervision.
Focus of Care	Restoring independence and functional ability.	Maintaining health and providing a safe, supportive living environment.

Preparing for a Smooth Transition

• Create a Communication Plan: Ensure all family members and caregivers are on the same page regarding the patient's care plan and wishes. Designate one person to serve as the primary point of contact.
• Gather Personal Belongings: Pack a bag with essential personal items, including clothing, toiletries, and any comfort items. Remember to label all belongings clearly.
• Arrange Advance Directives: Ensure all advance directives, such as a Medical Power of Attorney or a living will, are prepared and accessible.
• Understand Discharge Planning: The SNF will develop a discharge plan from day one. Be an active participant in this process to ensure a safe transition home or to another care setting.
• Leverage Case Managers: Both the hospital and the SNF have case managers or social workers who can provide invaluable guidance throughout the admission and transition process. Do not hesitate to use them as a resource.

Conclusion

Navigating admission to a skilled nursing facility requires careful attention to medical necessity, financial requirements, and administrative procedures. By understanding the criteria, assembling the necessary documentation, and coordinating effectively with healthcare and insurance providers, you can ensure a smoother and less stressful transition. Remember to differentiate between short-term rehab, which Medicare primarily covers, and long-term custodial care, which typically requires other funding sources like Medicaid or long-term care insurance. Armed with this knowledge, families can make informed decisions and advocate for the best possible care for their loved ones.

Center for Medicare Advocacy: "Discharge" from a Skilled Nursing Facility is a useful resource for understanding patient rights.

Frequently Asked Questions

What is the difference between a SNF and a nursing home?

A SNF provides short-term, intensive medical care and rehabilitation by licensed professionals after a hospital stay, with the goal of returning home. A nursing home offers long-term, custodial care for chronic conditions, assisting with daily living activities.

Does Medicare pay for long-term care in a SNF?

No, Medicare does not cover long-term or custodial care. It only provides limited coverage for short-term, medically necessary skilled nursing or therapy services following a qualifying hospital stay.

What is a qualifying hospital stay for Medicare coverage?

A qualifying hospital stay is an inpatient admission of at least three consecutive days, not including the day of discharge. A hospital stay for observation services does not count toward this requirement.

How soon do I need to be admitted to a SNF after a hospital stay?

To qualify for Medicare benefits, you must be admitted to the SNF within a short time, generally 30 days, of being discharged from the hospital.

What if I need long-term care in a SNF?

If you require long-term care, Medicare will not cover the costs. Payment options typically involve private funds, long-term care insurance, or Medicaid for those who meet financial eligibility requirements.

What documents do I need for SNF admission?

You will need a physician's order for admission, medical history and physical results, a detailed medication list, insurance documentation, and any relevant legal paperwork like advance directives.

Can I appeal if my Medicare coverage for a SNF stay is denied or terminated?

Yes, you have the right to appeal if you disagree with a termination of Medicare-covered services in a SNF. You can work with a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to appeal.