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Medicare Coverage of Florida Skilled Nursing Facility

 

Medicare may help pay for skilled nursing facility care if:

  • You need Florida skilled nursing care seven days a week or skilled therapy services at least five days a week;
  • You were formally admitted as an inpatient to a Florida hospital for at least three consecutive days. You must enter a Florida Medicare-certified skilled nursing facility within 30 days of leaving the hospital;
  • You have Medicare Part A before you are discharged from the hospital; and 
  • You need care that can only be provided in a Florida Skilled Nursing Facility.

If you meet these requirements, Medicare should cover the Floridaskilled nursing facility care needed to improve your condition or maintain your ability to function. Although you may hear otherwise, Medicare should cover skilled care that helps you maintain your ability to function or helps prevent or slow you from getting worse.

Note: If you are admitted to the emergency room under observation or only receive emergency room services, this time does not count toward meeting the three-day prior hospital requirement for Florida SNF coverage.

Home care is a phrase commonly used to refer to a wide range of health and social services. These services are delivered at home to recovering, chronically or terminally ill persons or people with disabilities in need of medical, nursing, social or therapeutic treatment, and/or assistance with the essential activities of daily living.

Medicare will help pay for your Florida home care if all four of the following are true:

  1. You are considered home-bound. Medicare considers you home-bound if you meet the following criteria:
    • You need the help of another person or special equipment (walker, wheelchair, crutches, etc.) to leave your home or your doctor believes that leaving your home would be harmful to your health; and
    • It is difficult for you to leave your home and you typically cannot do so.
  2. You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care as little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy.
  3. Your doctor signs a home health certification stating that you qualify for Medicare home care because you are home-bound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare.
    • As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive Florida home health care or within 30 days after you have already started receiving Florida home health care. Your doctor must specifically state that the face-to-face meeting confirmed that you are home-bound and qualify for intermittent Florida skilled care.
    • The face-to-face encounter can also be done through tele-health. In certain areas, Medicare will cover examinations done for you in specific places ( Florida doctors offices, Florida hospitals, Florida health clinics, Florida skilled nursing facilities) through the use of telecommunications (such as video conferencing).
  4. You receive your care from a Medicare-certified Florida home health agency (HHA).

*If you only need occupational therapy, you will not qualify for the Medicare home health benefit. However, if you qualify for Medicare coverage of Florida home health care on another basis, you can also get occupational therapy. Even when your other needs for Medicare home health end, you should still be able to get occupational therapy under the Medicare home health benefit if you continue to need it.

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