In 2024, 1,226,089 people were living in a certified skilled nursing facility. Considering that the demand for skilled nursing facilities is only expected to grow as the population ages, it’s never too early to start researching and bettering your understanding of skilled nursing care eligibility.
Many families will face some tough decisions when/if a loved one begins to require more care than what can be provided at home or in an assisted living facility. This article will help families plan for the appropriate healthcare services, clarify who qualifies for skilled nursing, and explain which medical conditions require skilled nursing. Plus, it will help explain coverage options, like Medicare.
Are you looking for skilled nursing care in Arizona? Check out Haven Health to learn about the comprehensive care we offer today.
What Is Skilled Nursing Care?
According to Medicare.gov, skilled nursing care involves medical services licensed nurses provide under a doctor’s supervision. This type of post-acute care is intended to treat and evaluate a patient’s medical condition until they can move to a more independent living situation. The National Library of Medicine explains that skilled nursing care is often for patients who are ready to leave the hospital after an injury, major surgery, or illness, but are still unable to care for themselves independently.
Skilled Nursing vs. Assisted Living
According to the National Institute on Aging (NIH), assisted living facilities are communities that provide long-term care to residents with varying levels of assistance with daily living support (such as grooming, meals, housekeeping, laundry, medication administration, etc.).
In assisted living communities, residents tend to live in their own room or small apartment but share communal spaces for socializing, eating, and other activities. While some assisted living facilities offer skilled nursing services, they don’t all provide continued access to medically trained staff (if at all). Skilled nursing services are always provided by medically trained staff. Patients at a skilled nursing facility are generally there because of medical necessity, as opposed to merely requiring assistance with daily activities due to aging or a worsening medical condition.
Skilled Nursing vs. Rehabilitation
In some cases, skilled nursing care and rehabilitation services may be provided at the same facility. For example, at Haven Health, you will find skilled nursing care services and rehabilitation services. However, in many cases, rehabilitation services can be provided as short-term outpatient treatments, like physical therapy or speech therapy, whereas skilled nursing services tend to be inpatient medical services needed for an extended period under the supervision of a licensed doctor.
Who Qualifies for Skilled Nursing Care?
Who does and does not qualify for skilled nursing care can be confusing. Not only can it depend on the specifics of the condition but also on what your specific insurance plan says “qualifies” you for it to be covered. For clarifying questions about what qualifies a patient for skilled nursing care in Arizona, contact Haven Health today.
Key Eligibility Criteria for Skilled Nursing Services
- A doctor’s order
- A qualifying condition that requires daily skilled care, such as IV therapy, wound care, or extensive rehabilitation services
- Functional care for an injury or recovering post-hospitalization
Examples of Qualifying Conditions
- Someone recovering from a stroke who needs daily physical therapy to regain normal function
- Post-surgical patients who require wound care and IV antibiotics
- Patients with complex medication management who require skilled supervision for administration and safety
Medical Conditions That May Require Skilled Nursing Care
- Recovery from a stroke or another neurological disorder
- Post-surgical rehabilitation care
- Management for a chronic illness, such as complications from diabetes or heart failure
- Essential wound care for surgical wounds, pressure ulcers, etc.
- Respiratory care for lung conditions, such as chronic obstructive pulmonary disease (COPD)
- Severe mobility limitations that require specialized therapy
Medicare and Insurance Eligibility for Skilled Nursing Care
According to Medicare.gov, the Medicare coverage requirements for skilled nursing are:
- You must have a qualifying hospital stay (a qualifying hospital stay is a hospital stay that lasts at least three days).
- You will require a doctor’s certification stating that a skilled nursing facility is a necessity for your treatment.
- You must enter the skilled nursing facility within 30 days of leaving the hospital.
- You require treatment for an ongoing medical issue to maintain or better your condition. This can be true even for medical issues that may not have been the reason you were initially admitted to the hospital.
Coverage Details
Under an Original Medicare Plan
- Days one-20: The first 20 days of a stay at a skilled nursing facility are usually completely covered by Medicare. However, keep in mind that there may be a co-payment if you’re under the Medicare Advantage Plan. Be sure to double-check with your specific coverage.
- Days 21-100: After the first 20 days, a co-payment will be required for Medicare patients. Medicare.gov lists this price at $209.50 per day.
- Beyond 100 days: Medicare will no longer cover your treatment after 100 days in a skilled nursing facility. If skilled nursing care is still required, you will either need to pay out of pocket, look into supplemental insurance, or discuss other options.
Private Insurance & Medicaid
Insurance coverage through a private insurance company or Medicaid will vary depending on your specific insurance plan. In some situations, prior authorization may be needed for costs to be covered. According to the American Council on Aging, patients in Arizona who meet the following criteria (specific to 2025 rules) should qualify for Medicaid:
- Income under $2,901 per month
- Assets under $2,000
- Require the skilled nursing level of care
Note: In Arizona, failing to meet all of the criteria doesn’t automatically mean you do not qualify for Medicaid to cover long-term skilled nursing care. Speak to the financial office at the skilled nursing facility you’re considering for more information.
How to Apply for Skilled Nursing Care
While these steps may vary slightly by state, insurance coverage, and the individual condition, the following are the general steps to be taken when applying for skilled nursing care.
The Step-By-Step Process
Step one: Obtain a physician’s referral for skilled nursing care.
Step two: Verify specific insurance coverage and benefits.
Step three: Choose a Medicare-approved skilled nursing facility for better coverage options and treatment options.
Step four: Complete admission paperwork and medical assessment. Ideally, the medical assessment should be done by the doctor providing the referral.
Step five: Develop a care plan with the nursing team.
Bonus Tips for Families
When choosing a skilled nursing facility for your loved one, it’s important to tour a few locations and get a feel for each place. Here are some specific things to focus on when taking your tour:
- Ask about facility ratings, quality measures, and safety protocols
- Understand all financial responsibilities upfront
- Ask about visiting and other forms of communication (phone calls, assistance with video chats, etc.)
- Ask about meal services and if you can try the food
Alternatives To Skilled Nursing Care
If a patient does not qualify for skilled nursing care on an inpatient basis, there are other options, such as:
Home Health Care
Not only are some patients adamant about not leaving their homes, but without a qualifying hospital stay, some may not be eligible for inpatient skilled nursing services. Luckily, in most cases, Medicare provides coverage for skilled services at home.
At-home care is when a qualified nurse or nurse practitioner comes to your home to provide skilled nursing services. This can be a preferable option for some, but it isn’t generally a suitable solution for those requiring 24-hour supervision, as at-home care tends to be limited to 28 hours per week.
Assisted Living
Assisted living facilities offer various services to assist with daily living, such as grooming services, meal services, laundry services, housekeeping services, etc. While this won’t be an option for patients still requiring 24-hour medical care, a temporary stay can be an option for those recovering from an injury that requires more assistance than a family may be able to provide.
Outpatient Rehabilitation
If the patient is in a situation where they can still drive themselves to rehabilitation appointments (or have a family member or friend who can take them), doing this on an outpatient basis can be more cost-effective. Heaven Health offers rehabilitation services like physical therapy, as part of individualized treatment plans, including inpatient and outpatient sessions.
Hospice or Palliative Care
For serious conditions (some that may be fatal), looking into palliative care options can be more cost-effective and comfortable for the patient long-term.
It’s never too early to be looking into what qualifies you or a loved one for skilled nursing care, especially when considering that insurance coverage can change over time. When a loved one begins to need daily assistance and/or suddenly becomes injured or ill, requiring more care than you can provide alone, it’s better to be prepared. If you’re still looking for more information, contact Haven Health for a skilled nursing care consultation today.
Additional resources:
- Medicare guidelines for skilled nursing facility care
- Arizona’s state-specific eligibility requirements
Are you looking for skilled nursing care in Arizona? Contact Haven Health today to learn more.
Sources:
Heiks, C. (2022). Long-Term Care and Skilled Nursing Facilities.
Home Health Services. (n.d.).
Long-Term Care Facilities: Assisted Living, Nursing Homes, and Other Residential Care. (2023).
Skilled Nursing Facility Care. (n.d.).
Skilled Nursing or Rehabilitation Facilities. (2023).
Total Number of Residents in Certified Nursing Facilities. (2024).