Medicare and skilled nursing care: the 3-day rule, 100 days and costs

A fall, a stroke or a joint replacement can leave someone well enough to leave the hospital but not yet able to manage at home. That in-between stage is often spent in a skilled nursing facility, and Medicare's rules for paying for it are some of the most misunderstood in the whole program. Families learn about the 3-day hospital rule, the 100-day limit and the difference between skilled care and long-term care at the moment they least have time to read the fine print.

This guide lays out those rules before you need them: when Original Medicare covers a stay, how many days it covers, what you pay in 2026, how breaks in care and benefit periods work, what to do if coverage is ending too soon, and the rights every resident has. It is based on the Centers for Medicare & Medicaid Services (CMS) booklet Medicare Coverage of Skilled Nursing Facility Care, with 2026 dollar amounts from the Medicare & You 2027 handbook.

What a skilled nursing facility is

CMS defines a skilled nursing facility (SNF) as a nursing facility with the staff and equipment to treat, manage and observe your condition and evaluate your care. SNFs are typically part of nursing homes but can also be part of a hospital. Care can come from doctors, registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists and other specialists. Physical therapy and intravenous injections given by a registered nurse or doctor are two of CMS's examples of SNF care.

The line that matters most is between skilled care and what CMS calls non-medical long-term care. Non-medical long-term care helps with daily activities like bathing and dressing, and can include things most people do for themselves, like using eye drops or oxygen or caring for a colostomy or bladder catheter. It is often given in the same nursing facility. Medicare does not cover non-medical long-term care when it is the only kind of care you need. A stay can start as covered skilled care and turn into uncovered long-term care in the same bed, which is why the rules below matter.

SNF care is generally given daily on a short-term basis. You may need skilled nursing care to improve your condition, or to maintain it and prevent or delay it from getting worse. Skilled therapy can be used to improve your condition, to set up a maintenance program, or to carry out a maintenance program safely when your condition or the services are complex. The handbook makes the same point plainly: you may get skilled nursing care or therapy if it is necessary to improve or maintain your current condition.

When Medicare covers a stay: every condition must be met

CMS says Original Medicare covers SNF care only if all of these are true:

• You have Part A and have days left in your benefit period.
• You had a medically necessary inpatient hospital stay of 3 consecutive days or more, called a qualifying hospital stay. You count the day you are admitted as an inpatient, and you do not count the day you are discharged.
• You enter the SNF within a short time, generally 30 days, of leaving the hospital.
• Your doctor has ordered inpatient SNF services that require the skills of professional personnel, and those skilled personnel provide or supervise them.
• You need skilled care daily, and as a practical matter it can only be given as an SNF inpatient. If you are there for skilled therapy only, it counts as daily if the therapy is needed and provided 5 to 7 days a week.
• You need skilled services for a condition that was also treated during your qualifying hospital stay (even if it was not the reason you were admitted), or for a new condition that started while you were getting SNF care for that condition.
• The services are reasonable and necessary for the diagnosis or treatment of your condition.
• You get them in a Medicare-certified SNF.

CMS's example of the new-condition rule: if you are in a SNF because you broke your hip and then have a stroke, Medicare may cover therapy for the stroke even if you no longer need therapy for the hip.

The 3-day rule and the inpatient trap

The qualifying stay has to be as an inpatient, and that is not the same as spending three nights in a hospital bed. The handbook explains that you are an inpatient when the hospital formally admits you with a doctor's order. You are an outpatient if you are getting emergency or observation services, lab tests or X-rays without a formal inpatient admission, even if you spend the night in the hospital.

Doctors sometimes keep a patient as an outpatient under observation while they decide whether to admit or discharge. If you are under observation more than 24 hours, the hospital must give you a Medicare Outpatient Observation Notice (MOON) explaining why you are an outpatient and how it affects what you pay in the hospital and for care after you leave. CMS's advice is to ask every day you are in the hospital, or have a caregiver ask the hospital, your doctor, a hospital social worker or a patient advocate, whether you are an inpatient or an outpatient. You also have appeal rights when a hospital changes your status from inpatient to outpatient, if you meet certain conditions; our Medicare appeals guide covers that process.

When the 3-day stay is not required

The handbook lists two exceptions. If your doctor participates in an Accountable Care Organization (ACO) approved for a Skilled Nursing Facility 3-Day Rule Waiver, you may not need the 3-day minimum stay; ask your doctor whether that applies. And Medicare Advantage Plans may also waive the 3-day minimum, so check with your plan. A third situation is in the SNF booklet: if you leave a SNF and re-enter the same or another SNF within 30 days, you may not need a new qualifying hospital stay.

How long Medicare covers SNF care: benefit periods and 100 days

Medicare counts SNF days within a benefit period. A benefit period begins the day you are admitted as an inpatient in a hospital or SNF, and you can get up to 100 days of SNF coverage in each one. The benefit period ends when you have gone 60 days in a row without inpatient hospital care or skilled care in a SNF. If you go back in after that, a new benefit period begins, with a new Part A deductible. CMS notes this can happen more than once in a calendar year, and there is no limit to the number of benefit periods.

What happens after a break in SNF care depends on how long the break lasts:

CMS walks through three examples, each assuming the person met all the coverage rules:

• Out less than 30 days. Mrs. Perkins got 10 days of covered SNF care after breaking her leg, went home when she no longer needed skilled care, and 10 days later her doctor decided she needed more skilled care for the leg. Medicare covers the new stay, and she has 90 days left in her benefit period.
• Out at least 30 but less than 60 days. Mr. Jones got 20 days of covered care after a stroke, paid for 2 more days of long-term care, and went home. After 34 days he was readmitted to the hospital for 4 days because of the stroke and then went back to a SNF. Medicare covers this stay because he had a new qualifying hospital stay, and he has 80 days left in the same benefit period.
• Out at least 60 days. Mrs. Smith got 20 days of covered care after back surgery and went home. After 65 days she was hospitalized for 3 days after a fall and then admitted to a SNF. Her old benefit period had ended, so the new stay starts a new benefit period with up to 100 days.

What Medicare pays for during a covered stay

When you qualify, Medicare covers:

• A semi-private room (a room you share with other patients).
• Meals.
• Skilled nursing care.
• Medical social services.
• Medications.
• Medical supplies and equipment used in the facility.
• Ambulance transportation, when other transportation would endanger your health, to the nearest supplier of medically necessary services the SNF does not offer, including the return trip.
• Dietary counseling.
• Physical therapy, occupational therapy and speech-language pathology services if they are needed to meet your health goal, such as being able to walk a certain distance or climb stairs.

What you pay in 2026

In Original Medicare, SNF costs are tied to the benefit period:

You do not pay the deductible again for SNF care if you already paid it for a hospital stay in the same benefit period, and because SNF coverage follows a qualifying hospital stay, that is often the case. Using every day from 21 through 100 means 80 days of coinsurance; at $217 a day, that adds up to $17,360 in 2026. You also pay any charges Medicare does not cover, like phone and laundry fees. If you are in a Medicare Advantage Plan, your costs may be different, so check with your plan. For the hospital side of the bill, see Part A costs.

Help with the costs

• Medicaid and your state. If your income and resources are limited, you may get help paying for SNF care, long-term care or other health costs. With both Medicare and Medicaid, most health care costs may be covered, and you may qualify for the Medicaid nursing home benefit or the Programs of All-inclusive Care for the Elderly (PACE). Call your State Medical Assistance (Medicaid) office. Our pages on Medicare Savings Programs and SSI for people 65 and older explain related programs.
• Medigap. Some Medigap policies pay all or part of the SNF coinsurance for days 21 through 100. Under CMS's 2026 benefit chart, Plans C, D, F, G, M and N cover it, Plans K and L pay 50% and 75%, and Plans A and B do not. Our Medigap guide compares the plans.
• Employer or union coverage. Check with your benefits administrator about what is covered.
• Long-term care insurance. Check your policy to see whether skilled or non-medical long-term care is covered.

Your State Health Insurance Assistance Program (SHIP) gives free counseling on all of these; find yours at shiphelp.org.

Finding and choosing a SNF

With Original Medicare you can go to any Medicare-certified SNF that has a bed available. If the hospital you are in has its own SNF with a bed, you may choose to stay there; most nursing homes also offer SNF care. In a Medicare Advantage Plan, you can usually go to any certified SNF, but an in-network SNF might save you money, some plans require one, and you may need to tell the plan before you are admitted or pay more, or all, of the cost.

CMS suggests four steps:

1. Find SNFs near you. Use Medicare.gov/care-compare and select "Nursing homes including rehab services." In the hospital, ask the discharge planner or social worker for a list; they may help you find a bed. A local social service agency, your doctor, family and friends can also help.
2. Compare quality. Care Compare shows health inspection reports, staffing levels, quality measures and star ratings. Your state survey agency, state health department and Long-Term Care Ombudsman are other sources; ask the ombudsman how many complaints a SNF has had, what kind, and whether they were resolved.
3. Visit. Tour in person if you can, or ask a family member or friend to go. Ask staff to show the staffing information they must post and the most recent health inspection report, and if problems were found, whether they were corrected. Ask whether you can sit in on a resident or family council meeting.
4. Choose. If more than one facility has a bed, compare everything you learned and make your arrangements.

The booklet's checklist is worth taking on a tour. Among its questions: Is the SNF Medicare and Medicaid certified, and does it offer the type of skilled care you need? Is there a full-time registered nurse in the building at all times, other than the administrator or director of nursing? Do the same nurses and certified nursing assistants work with the same reasonable number of residents 4 to 5 days a week? Is there a full-time social worker? Does it do background checks on all staff? Are residents clean and well groomed, with a choice of roommates, activities and food? Does it have an emergency evacuation plan, regular fire drills, sprinklers, smoke detectors and an arrangement with a nearby hospital? Has it corrected every issue from its last inspection?

Your care plan

Your care is based on your doctor's orders and on assessments by a team of staff. Medicare requires an initial assessment within your first 8 days. It covers your physical and mental condition, medical history, medications, how well you handle daily activities like bathing, dressing, eating and moving around, your speech, your decision-making ability, and limitations like hearing or vision problems or paralysis after a stroke. Staff then prepare a care plan listing the services you need, who will provide them, how often and for how long, the equipment and diet you need, and your health goals. You, your family or someone acting for you have the right to take part, and the plan is updated each time your condition is assessed.

When coverage ends, and how to appeal

When Medicare coverage of your stay is ending because care is no longer medically reasonable and necessary, or is considered non-medical long-term care, the SNF must give you a written Notice of Medicare Non-Coverage (NOMNC). If you think your covered services are ending too soon, you can ask for a fast appeal. The notice tells you how, and may call it an immediate or expedited appeal. If you do not get the notice, ask for it.

In a fast appeal, an independent reviewer called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) decides whether your services should continue. Call the BFCC-QIO at the number on your notice no later than the time the notice shows, and ask your doctor to send any information that may help. If you miss the deadline, you may still have appeal rights: with Original Medicare, call your BFCC-QIO; in a Medicare Advantage Plan, call your plan or your BFCC-QIO. The handbook adds that if you are discharged only because you are not improving, but still need skilled care to keep your condition from getting worse, you can appeal.

Two more rules protect your wallet. First, if coverage ends and you stay, an Original Medicare SNF must give you a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) or a denial letter before it can tell you to pay. That notice gives the date coverage ends, why, the estimated cost, and your right to have the SNF send a claim to Medicare for an official decision, sometimes called a demand bill. If you ask for that claim, you do not have to pay coinsurance or for non-covered services until you hear Medicare's decision. Second, the SNF does not have to warn you in writing when you run out of benefit days, so keep your own count.

CMS also urges planning ahead. After a SNF stay you may need help with shopping, bathing, dressing or transportation, or home health care. If you will need long-term care in a nursing facility, think early about where; staying in the same facility may be an option if it has a bed and you are happy with the care.

Your rights as a SNF resident

Under federal law, SNF residents have the right to:

• Freedom from discrimination based on race, color, national origin, disability, sex, age, diagnosis, severity of condition, payment source or religion, under certain conditions. The HHS Office for Civil Rights takes complaints at 1-800-368-1019 (TTY 1-800-537-7697).
• Respect, including setting your own schedule for sleeping, waking and meals and choosing your activities.
• Freedom from abuse and neglect by anyone, including staff, other residents, visitors and family. Report it to the SNF, your family, the Long-Term Care Ombudsman or your State Survey Agency; local law enforcement and the Medicaid Fraud Control Unit may also be appropriate.
• Freedom from restraints. Physical or chemical restraints are against the law unless needed to treat medical symptoms, and can never be used as punishment or for staff convenience.
• Written information on services and fees before you move in. The SNF cannot require a minimum entrance fee or charge for items or services you did not ask for.
• Control of your money. If the SNF manages your funds, you must authorize it in writing; money over $50 (with Medicaid) or $100 (with Medicare) must go in an interest-bearing account, with quarterly statements and protection against loss.
• Privacy and property, including private phone calls, unopened mail and sharing a room with your spouse if you both agree.
• Information about your medical care, seeing your own doctor, refusing treatment, and reading your records.
• Visitors at any reasonable time, and the right to refuse visitors you do not want to see.
• Medically related social services, including counseling, help contacting legal and financial professionals, and discharge planning.
• Complaining without fear of punishment, with the SNF required to resolve the issue promptly.
• Protection against unfair transfer or discharge. You can be moved or discharged only for your or others' welfare or safety, because your needs have outgrown the SNF or you no longer need SNF care, because you did not pay for services you owe, or because the SNF closes. A SNF cannot make you leave while you are waiting to get Medicaid.

If something goes wrong, start with the staff, then a supervisor, the social worker, the director of nursing or your doctor, and then the SNF's complaint procedure. Outside help is available from the Long-Term Care Ombudsman and the State Survey Agency, whose contact information the SNF must post. If you think charges are wrong, Original Medicare's Medicare Summary Notice lists the services you got and a number to call; in a Medicare Advantage Plan, call your plan.

Related reading

Long-term custodial care is the biggest gap in Medicare; our guide to what Medicare doesn't cover explains it alongside dental, vision and hearing. If you are weighing coverage options before a stay, see Original Medicare vs Medicare Advantage. For help, call 1-800-MEDICARE (1-800-633-4227); TTY users can call 1-877-486-2048.