Clinical Eligibility Requirements for Medicare SNF Coverage

A beneficiary is eligible for Skilled Nursing Facility (SNF) extended care under Medicare if all the following conditions are met:

1. Skilled Nursing or Rehabilitation Services: The patient requires skilled nursing services or skilled rehabilitation services. These services must be performed by or under the supervision of professional or technical personnel, are ordered by a physician, and are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which they received inpatient hospital services.
2. Daily Need for Skilled Services: The patient requires these skilled services on a daily basis.
3. Inpatient SNF Services: As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF.
4. Reasonable and Necessary Services: The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity​​.

These requirements ensure that Medicare beneficiaries receive the appropriate level of care in a SNF setting when it is medically necessary and cannot be adequately provided in a less intensive setting.