"Understanding Medicare and Managed Care: Skilled Nursing Facility Coverage Criteria"

Skilled care in a Skilled Nursing Facility (SNF) is covered under Medicare Part A when specific criteria are met. These criteria ensure that the care provided is necessary due to the patient's medical condition and requires the expertise of skilled professionals. The coverage criteria include:

1. Requirement for Skilled Nursing or Rehabilitation Services: The patient must need services that can only be provided by professional or technical personnel, such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists. These services must be ordered by a physician and necessary for treating a condition for which the patient received inpatient hospital services or a condition that arose while receiving care in an SNF for a condition for which the patient received inpatient hospital services.
2. Daily Need for Skilled Services: The patient requires these skilled services on a daily basis. This stipulation ensures that the care provided is not only necessary but also frequent enough to warrant an inpatient stay at an SNF.
3. Inpatient Basis Requirement: The skilled services must be such that, for reasons of economy and efficiency, they can only be provided in an inpatient setting. This criterion acknowledges that some care needs are too intensive or complex to be managed in a less structured environment.
4. Reasonable and Necessary Services: The services must be reasonable and necessary for the treatment of the patient's illness or injury, consistent with the severity of the individual's condition, medical needs, and accepted standards of medical practice. They must also be reasonable in terms of duration and quantity.

If any of these four factors are not met, a stay in an SNF, even if it includes the delivery of some skilled services, is not covered. For example, if a patient requires skilled services on an intermittent rather than a daily basis, Medicare Part A would not cover the SNF level of care. In assessing claims for SNF services, the primary consideration is whether there is a need for skilled care. If the need for skilled service is not present, then the requirements for daily care and the necessity of inpatient care are not considered. Documentation plays a crucial role in facilitating accurate coverage determinations for claims involving skilled care​​.