To qualify for skilled nursing care under Medicare, a patient must need medical services that can only be performed by or under the supervision of licensed professionals, such as registered nurses or therapists. This care must be needed on a daily basis, and the patient must have had a qualifying three-day inpatient hospital stay beforehand. Beyond those basics, several specific criteria determine whether Medicare will cover a stay in a skilled nursing facility (SNF).
The Three-Day Hospital Stay Requirement
Medicare Part A requires that you spend at least three consecutive midnights as a formally admitted inpatient in a hospital before transferring to an SNF. This rule remains firmly in place. CMS has acknowledged requests to eliminate it but stated it lacks the statutory authority to do so, and its own cost analyses show that removing the requirement would significantly increase Medicare spending.
The critical detail here is your admission status. If the hospital places you “under observation,” those hours do not count toward the three-day requirement, even if you spend multiple nights in a hospital bed receiving treatment. Observation is classified as outpatient care. Hospitals are required to give you a Medicare Outpatient Observation Notice (MOON) if you’ve been receiving observation services for more than 24 hours, which explains your status and warns you about the downstream effects on SNF coverage. If you or a family member suspect a hospital stay might lead to SNF care, confirming inpatient status early is one of the most important things you can do.
Skilled Care vs. Custodial Care
The distinction between skilled and custodial care is the single biggest factor in whether Medicare covers a nursing facility stay. Skilled nursing care is provided by trained registered nurses in a medical setting under a doctor’s supervision, essentially the same level of nursing care you’d receive in a hospital. The goal is transitional: to recover enough to go home.
Custodial care, by contrast, focuses on help with daily activities like dressing, bathing, and eating. It’s provided mostly by licensed practical nurses and nurse aides, and it’s designed for people who need long-term residential support rather than active medical treatment. Medicare does not cover custodial care. If your only needs are help getting dressed, reminders to take medication, or general supervision, that does not meet the threshold for skilled care, regardless of how much assistance you require.
Services That Qualify as Skilled Care
Federal regulations spell out specific services that count as skilled nursing or skilled rehabilitation. On the nursing side, qualifying services include:
- IV or intramuscular injections and intravenous feeding
- Tube feeding that provides at least 26% of daily calorie needs and at least 501 milliliters of fluid per day
- Suctioning of the airway through a nasopharyngeal tube or tracheostomy
- Catheter care, including insertion, sterile irrigation, and replacement of suprapubic catheters
- Wound dressings that involve prescription medications and sterile technique
- Treatment of severe pressure ulcers or other widespread skin conditions
- Medically ordered heat treatments that require nurse observation to evaluate progress
- Medical gas administration during the initial setup phase
- Bowel and bladder retraining programs as part of rehabilitation nursing
On the rehabilitation side, qualifying services include physical therapy, occupational therapy, and speech-language pathology. These count as skilled when the exercises or activities are complex enough that they must be performed by or supervised by a licensed therapist to keep the patient safe and the treatment effective. Routine exercises that an aide could safely walk you through do not qualify.
Two less obvious categories also count. Observation and assessment qualifies as skilled care when a professional needs to monitor your condition and decide whether your treatment plan needs to change. And patient education qualifies when a nurse or therapist needs to teach you how to manage your own care after discharge, such as learning to use new medical equipment or adjust to a changed physical condition.
The Daily Care Requirement
Medicare requires that skilled services be needed and provided on essentially a daily basis. For skilled nursing services, that means seven days a week. For skilled rehabilitation services alone, the minimum is five days a week.
You can meet this requirement by combining different types of skilled services across the week, but there’s an important catch. Simply staggering therapy sessions across different days to fill the calendar doesn’t count. If you receive physical therapy three days a week and occupational therapy two other days, that satisfies the daily requirement only if there’s a genuine medical reason the two therapies can’t happen on the same day. The need for daily skilled care must come from your medical condition, not from scheduling creativity.
The services must also be reasonable in amount, frequency, and duration relative to what they’re expected to achieve. If the anticipated improvement would be minimal compared to the therapy required to get there, Medicare may not consider the services reasonable or necessary.
Physician Certification
A doctor must formally certify that you need skilled nursing facility care. This certification must confirm that you require skilled care on a daily basis for a condition you were being treated for in the hospital (or for a new condition that developed after arriving at the SNF). The certification should be obtained at the time of admission or as soon afterward as is reasonably practical.
The attending physician, a physician on the SNF’s staff who knows your case, or in some situations a nurse practitioner, clinical nurse specialist, or physician assistant can sign the certification. After the initial certification, recertification is required no later than the 14th day of your stay. After that, recertifications happen at least every 30 days. Each recertification must document the reasons you still need skilled care, estimate how much longer you’ll need to stay, and outline any plans for transitioning to home care.
How Long Coverage Lasts and What It Costs
Medicare Part A covers up to 100 days per benefit period in a skilled nursing facility. For the first 20 days, you pay nothing beyond your Part A deductible. From day 21 through day 100, you’re responsible for a daily copayment of $217 in 2026. After day 100, Medicare coverage ends entirely, and you pay the full cost out of pocket.
Your benefit period resets after you’ve gone 60 consecutive days without receiving skilled nursing facility care. If you’re readmitted to an SNF after that 60-day gap, a new benefit period begins, restarting the 100-day clock. Keep in mind that coverage doesn’t automatically last the full 100 days. It continues only as long as you meet the medical criteria for daily skilled care. The moment your condition stabilizes to the point where skilled services are no longer needed on a daily basis, coverage stops.
What Happens When Coverage Ends
When your SNF or Medicare plan determines you no longer qualify for skilled care, you must receive a written Notice of Medicare Non-Coverage (NOMNC) at least two days before services are set to end. This notice explains why coverage is being terminated and tells you how to appeal.
You have the right to request an expedited review. The notice must include the contact information for filing that appeal. If you’re unable to understand the notice due to your medical condition, it must be delivered to and signed by your representative. This appeals process exists because coverage decisions aren’t always clear-cut. If your care team believes you still need skilled services, or if you feel your condition hasn’t improved enough for discharge, requesting a review can sometimes extend your covered stay while the decision is reconsidered.