Georgia Medicare SNF Benefit: Coverage Guide

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By Brevy Care Team · Last verified May 13, 2026

The Medicare Skilled Nursing Facility (SNF) Benefit is one of the most heavily utilized Medicare Part A benefits, providing post-acute care for beneficiaries discharged from the hospital who need skilled nursing or skilled rehabilitation care that cannot be provided at home. Section 1812(a)(2) of the Social Security Act, codified at 42 USC 1395d(a)(2), establishes SNF services as covered Medicare Part A inpatient care. Section 1861(i) of the Act defines extended care services and establishes the requirement that the beneficiary must have had a qualifying inpatient hospital stay of at least 3 consecutive days. Section 1812(b)(2) provides that the benefit is limited to 100 days per spell of illness. Section 1888(e) of the Act establishes the SNF prospective payment system, which has been refined multiple times and most recently was reorganized into the Patient-Driven Payment Model (PDPM), effective October 1, 2019. Section 1888(g) and 1888(h) establish the SNF Value-Based Purchasing Program, created by Section 215 of the Protecting Access to Medicare Act of 2014.

This guide explains the Medicare SNF Benefit as it applies to Georgia beneficiaries. It walks through the 3-day qualifying inpatient hospital stay requirement (and the critical distinction from observation status), the daily skilled need standard (including the Jimmo v. Sebelius clarification that maintenance therapy is covered without an improvement requirement), the 100-day benefit per spell of illness (with full coverage for days 1 through 20 and daily coinsurance for days 21 through 100), the Patient-Driven Payment Model with its five case-mix components, the SNF Value-Based Purchasing Program tied to 30-day readmissions, the waivers of the 3-day stay requirement available to Accountable Care Organizations and Medicare Advantage plans, the discharge appeals process through Georgia's Quality Improvement Organization KEPRO, and the practical pathway for Georgia families to access SNF care from facilities across the state. :::

Federal Statutory and Regulatory Authority

Section 1812(a)(2) of the Social Security Act (42 USC 1395d(a)(2))

Section 1812(a)(2) establishes post-hospital extended care services in a skilled nursing facility as one of the core Medicare Part A benefits. The section is the statutory foundation for the SNF benefit and authorizes Medicare payment for the SNF services that meet the requirements of Section 1861(i) and the implementing regulations.

Section 1812(b)(2) of the Social Security Act

Section 1812(b)(2) establishes the 100-day benefit limit per spell of illness. The statute sets a quantitative limit on SNF coverage that operates alongside the qualitative skilled need requirement: even if the beneficiary continues to need skilled care, Medicare will not pay for more than 100 days of SNF care in a single spell of illness.

Section 1861(i) of the Social Security Act (42 USC 1395x(i))

Section 1861(i) defines extended care services. The definition includes the 3-day qualifying hospital stay requirement: the beneficiary must have been a hospital inpatient for at least 3 consecutive days within 30 days before SNF admission, and the SNF stay must be for a condition treated during the qualifying hospital stay (or for a condition that arose while in the SNF). This statutory requirement is the source of the much-misunderstood "3-day stay rule" and the related observation status issues.

Section 1861(h) of the Social Security Act

Section 1861(h) defines "skilled nursing facility" for Medicare purposes. A SNF is an institution primarily engaged in providing skilled nursing care and rehabilitation services, that meets the requirements of Section 1819 (SNF Conditions of Participation).

Section 1819 of the Social Security Act

Section 1819 establishes SNF Conditions of Participation. The section was substantially expanded by the Nursing Home Reform Act provisions of the Omnibus Budget Reconciliation Act of 1987 (Sections 4201 through 4218 of Public Law 100-203). Implementing regulations are at 42 CFR Part 483.

Section 1888(e) of the Social Security Act

Section 1888(e) establishes the SNF prospective payment system (PPS). Added by Section 4432 of the Balanced Budget Act of 1997, Section 1888(e) replaced cost-based reimbursement with a prospective per-diem payment system. The current implementation of the PPS is the Patient-Driven Payment Model (PDPM), effective October 1, 2019.

Section 1888(g) and 1888(h) of the Social Security Act

Sections 1888(g) and 1888(h) establish the SNF Value-Based Purchasing Program. Created by Section 215 of the Protecting Access to Medicare Act of 2014 (Public Law 113-93), SNF VBP became effective October 1, 2018.

42 CFR Part 483: Requirements for Long-Term Care Facilities

The Conditions of Participation for SNFs and Nursing Facilities are codified at 42 CFR Part 483. Subpart B addresses requirements for SNFs and NFs and includes regulations on resident rights (42 CFR 483.10), freedom from abuse, neglect, and exploitation (42 CFR 483.12), admission, transfer, and discharge rights (42 CFR 483.15), resident assessment via the Minimum Data Set (42 CFR 483.20), comprehensive person-centered care planning (42 CFR 483.21), quality of life (42 CFR 483.24), quality of care (42 CFR 483.25), nursing services (42 CFR 483.35), and infection control (42 CFR 483.80).

42 CFR 409.20 through 409.36: Coverage Requirements

The SNF coverage requirements are codified at 42 CFR 409.20 through 409.36. Key regulations include:

• 42 CFR 409.22: Conditions for coverage of post-hospital SNF services (qualifying hospital stay)
• 42 CFR 409.23: Definition of "spell of illness"
• 42 CFR 409.30: Requirement that beneficiary need skilled services on a daily basis
• 42 CFR 409.31: Skilled services definition
• 42 CFR 409.32: Criteria for skilled services
• 42 CFR 409.33: Examples of skilled nursing and rehabilitation services
• 42 CFR 409.35: Criteria for daily basis
• 42 CFR 409.36: Practical matter criteria

42 CFR 424.20: Physician Certification

The certifying physician must certify and recertify medical necessity at admission and at intervals required by CMS regulation.

Statutory History

The Medicare SNF benefit was part of the original Medicare program established by the Social Security Amendments of 1965. The Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) established the Nursing Home Reform Act provisions, transforming SNF and nursing facility regulation. The Balanced Budget Act of 1997 (Public Law 105-33) Section 4432 created the SNF prospective payment system. The Balanced Budget Refinement Act of 1999 (Public Law 106-113) and the Benefits Improvement and Protection Act of 2000 (Public Law 106-554) refined the PPS. The Affordable Care Act of 2010 (Public Law 111-148) added Section 3022 Medicare Shared Savings Program ACOs (with SNF 3-day waiver authority), Section 6101 ownership disclosure, and Section 6111 civil money penalties. The Protecting Access to Medicare Act of 2014 (Public Law 113-93) Section 215 created the SNF Value-Based Purchasing Program. The IMPACT Act of 2014 (Public Law 113-185) standardized post-acute care quality measures. The Patient-Driven Payment Model (PDPM) replaced the prior RUG-IV system effective October 1, 2019.

The Jimmo v. Sebelius Settlement Agreement (January 24, 2013) was a court-approved settlement clarifying that Medicare coverage of skilled services does not require improvement potential. Maintenance therapy is covered if skilled-level care is required.

::: callout Key Takeaways

• Section 1812(a)(2) of the Social Security Act establishes the Medicare SNF benefit as covered Part A inpatient care. Section 1861(i) defines extended care services and the qualifying hospital stay requirement.

• The 3-day qualifying inpatient hospital stay must be 3 consecutive midnights of inpatient (not observation) status. The Two-Midnight Rule guides inpatient/observation decisions. The NOTICE Act and Medicare Outpatient Observation Notice (MOON) require hospitals to disclose observation status.

• The 100-day SNF benefit per spell of illness covers days 1 through 20 fully and requires daily coinsurance ($217 per day for FY 2026) for days 21 through 100. After day 100, the beneficiary pays full SNF rates.

• Under Jimmo v. Sebelius (2013), Medicare coverage does NOT require improvement potential. Maintenance therapy is covered if the services require skilled level of care. This standard applies in SNF, home health, and outpatient therapy.

• The Patient-Driven Payment Model (PDPM), effective October 1, 2019, replaced the prior RUG-IV system. PDPM eliminates therapy volume as the primary payment driver and uses five case-mix components based on patient characteristics: PT, OT, SLP, Nursing, and Non-Therapy Ancillaries. :::

The 3-Day Qualifying Hospital Stay

The 3-day qualifying inpatient hospital stay is the foundational requirement for Medicare SNF coverage. It is also one of the most frequently misunderstood and litigated aspects of the SNF benefit.

Statutory Basis

Section 1861(i) of the Social Security Act requires that the beneficiary have been a hospital inpatient for at least 3 consecutive days before SNF admission, and that the SNF admission be related to the qualifying hospital stay condition or a condition arising during the SNF stay.

What Counts: Inpatient Status

The 3 consecutive days must be inpatient status. The hospital must have admitted the beneficiary as an inpatient under a physician order. Inpatient status is documented by the hospital admission and discharge dates and is reflected in the Medicare claim.

What Does Not Count: Observation Status

Observation status is technically outpatient care even when the beneficiary is in a hospital bed receiving hospital-level care. Time spent in observation does NOT count toward the 3-day qualifying stay.

This distinction has been a significant source of denied SNF claims and family financial distress. A beneficiary who spends 3 days in observation followed by SNF admission does not have a qualifying stay, regardless of the medical reality of those 3 days.

The Two-Midnight Rule

The Two-Midnight Rule, codified at 42 CFR 412.3 and effective FY 2014, provides guidance on inpatient versus observation status determination. Under the rule:

• If the admitting physician reasonably expects the beneficiary to require hospital care that spans at least two midnights, inpatient admission is generally appropriate
• If the expected stay is less than two midnights, observation status is generally appropriate
• The physician's reasonable expectation, documented at admission, controls

The Two-Midnight Rule has been modified by subsequent CMS guidance to allow some shorter inpatient stays for procedures on the inpatient-only list and case-by-case exceptions.

The NOTICE Act and MOON

The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act, Public Law 114-42), effective March 8, 2017, requires hospitals to provide the Medicare Outpatient Observation Notice (MOON, Form CMS-10611) to beneficiaries in observation status for more than 24 hours.

The MOON must:

• Inform the beneficiary that they are in observation status (outpatient)
• Explain the financial implications including potential SNF coverage exclusion
• Be delivered orally and in writing

The MOON does not change observation status; it only requires disclosure. The disclosure allows beneficiaries to advocate for inpatient admission if appropriate or to plan for the financial consequences of observation status.

How to Count the 3 Days

• Count the date of inpatient admission
• Do NOT count the date of discharge
• 3 consecutive midnights must pass during inpatient status

Example: Admitted as inpatient January 1; discharged January 4. Inpatient nights are January 1, January 2, January 3 (three consecutive midnights). 3-day stay qualified.

Example: Admitted to observation January 1; converted to inpatient January 2; discharged January 4. Inpatient nights are January 2 and January 3 (two consecutive midnights). 3-day stay NOT qualified.

Admission Within 30 Days

The SNF admission must generally occur within 30 calendar days of hospital discharge. Limited medical exception exists if SNF admission would not have been appropriate within 30 days but would have been appropriate at the time of hospital discharge.

Same Condition Rule

The SNF stay must be for a condition treated during the qualifying hospital stay, or for a condition that arose while the beneficiary was receiving SNF care for the qualifying condition.

The 100-Day Benefit Per Spell of Illness

Days 1 Through 20: Full Coverage

Medicare covers 100% of the Medicare-approved amount for SNF days 1 through 20. The beneficiary pays no daily coinsurance.

Days 21 Through 100: Daily Coinsurance

For days 21 through 100, the beneficiary pays daily coinsurance. The coinsurance amount is $217 per day for FY 2026 (the amount is adjusted annually under Section 1813(a)(3) of the SSA). Over 80 days of coinsurance, this totals $17,360.

Medicare Supplement (Medigap) plans typically cover this coinsurance for beneficiaries in Original Medicare. Medicare Savings Programs cover the coinsurance for eligible dual-eligibles (QMB-level beneficiaries).

After Day 100: Beneficiary Pays Full Rate

After day 100 in a single spell of illness, Medicare provides no further SNF coverage. The beneficiary is responsible for the full SNF rate (which varies by facility and region but typically ranges from $250 to $400 per day in Georgia).

The Spell of Illness

A spell of illness:

• Begins on the first day of inpatient hospital or skilled SNF care
• Ends after 60 consecutive days during which the beneficiary has not been in a hospital and has not received skilled SNF care
• After a 60-day break, a new spell of illness begins with a fresh 100-day SNF benefit

The 60-day break is strict: any hospital admission or any day of skilled SNF care during the 60 days resets the clock. Outpatient care, home health, hospice, and other non-inpatient services do not affect the 60-day count.

Practical Implications

A beneficiary who exhausts the 100-day benefit and is later re-hospitalized cannot immediately access a new 100-day benefit. The 60-day break is required to reset the spell of illness. For long-term care, this often means that beneficiaries who exhaust Medicare SNF days transition to Medicaid long-term care or other arrangements rather than waiting for a new spell of illness.

The Daily Skilled Need Standard

The daily skilled need standard is the second pillar of SNF coverage. Even with a qualifying hospital stay, the beneficiary must require skilled services on a daily basis for SNF coverage to continue.

What "Daily" Means

Under 42 CFR 409.35:

• For skilled nursing services alone: 7 days per week
• For skilled therapy services alone: 5 days per week (interpreted flexibly to allow brief gaps)
• For a combination of skilled nursing and therapy: depends on the services

The "daily" requirement is interpreted with some flexibility. A weekend break in therapy does not necessarily disqualify; the question is whether the beneficiary's overall course of care requires daily skilled intervention.

Skilled Nursing Services

Examples of skilled nursing services that may justify SNF coverage:

• Complex wound care (stage 3 or 4 ulcers, complex surgical wounds, infected wounds requiring debridement or specialized dressing)
• IV therapy (antibiotics, fluids, complex medication regimens)
• Ostomy care (new colostomies, ileostomies, urostomies during the teaching and adjustment period)
• Tracheostomy care
• Tube feedings (gastrostomy, nasogastric)
• Catheter care (complex urological)
• Skilled observation and assessment for unstable conditions (acute or rapidly changing medical conditions requiring frequent reassessment)
• Teaching for new diagnoses (newly diagnosed diabetes with insulin, newly initiated anticoagulation, new ostomy)
• Injection management in certain complex situations

Routine custodial tasks (assistance with ADLs, simple medication administration, routine catheter care after teaching is complete) are NOT skilled services.

Skilled Therapy Services

Examples of skilled therapy:

• Physical therapy: gait, transfers, balance, strengthening, range of motion, post-surgical rehabilitation
• Occupational therapy: ADLs, fine motor coordination, cognitive function, adaptive equipment
• Speech-language pathology: dysphagia evaluation and treatment, aphasia, dysarthria, cognitive-communication

The Jimmo v. Sebelius Settlement

The Jimmo v. Sebelius Settlement Agreement, approved by the federal court on January 24, 2013, was a watershed moment for Medicare coverage of skilled services.

The Issue: For decades, CMS contractors and SNFs had been applying an unwritten "improvement standard," denying coverage when the beneficiary's condition was not improving. Beneficiaries with chronic conditions (MS, Parkinson's, advanced dementia, post-stroke deficits, ALS) often faced premature discharge or denial of coverage because their condition was stable or declining despite needing skilled care.

The Settlement: The court approved a settlement requiring CMS to:

• Clarify that maintenance therapy is covered when skilled services are required
• Issue Manual revisions explicitly rejecting any "improvement standard"
• Conduct an educational campaign for contractors, SNFs, and advocates
• Re-review certain denied claims

The Standard: Medicare covers skilled services in SNF when:

• The services are reasonable and necessary for the beneficiary's condition
• The services can only be performed safely and effectively by or under supervision of skilled personnel
• The services are performed daily (per the daily standard)

Improvement is NOT required. Services to maintain current function or prevent further decline are covered if they require skilled level of care.

Maintenance Therapy Examples:

• Maintenance PT for chronic neurological conditions to prevent contractures or maintain mobility
• Maintenance SLP for chronic dysphagia to prevent aspiration
• Skilled nursing assessment for unstable chronic conditions
• Skilled care for advanced dementia with safety concerns

CMS issued clarifying guidance after Jimmo emphasizing that the maintenance standard applies in SNF, home health, and outpatient therapy.

Custodial Care Distinction

SNF Medicare coverage is for skilled care, not custodial care. Custodial care includes:

• Assistance with ADLs (bathing, dressing, toileting, grooming, transferring) without a concurrent skilled need
• Routine medication administration after teaching is complete
• General supervision
• Routine catheter care after the initial teaching and stabilization period
• Routine personal care

Beneficiaries needing only custodial care should be evaluated for long-term care arrangements: Medicaid nursing facility coverage, assisted living, or home-based care.

The Patient-Driven Payment Model (PDPM)

PDPM was implemented effective October 1, 2019 under the FY 2019 SNF PPS Final Rule. PDPM is the most significant SNF payment reform since the SNF PPS was implemented in 1998 and replaced the prior Resource Utilization Group (RUG-IV) system.

Why PDPM Replaced RUG-IV

The RUG-IV system paid based largely on therapy minutes provided. Critics argued this incentivized therapy overprovision not tied to patient need. PDPM was designed to:

• Tie payment to patient characteristics rather than therapy volume
• Reduce incentive for therapy overprovision
• Better recognize complex medical conditions including non-therapy care needs
• Promote care delivery efficiency

PDPM Structure: Five Case-Mix Components

PDPM payment is calculated by adding five case-mix-adjusted components plus a non-case-mix-adjusted base:

1. Physical Therapy (PT): Case-mix based on PT clinical category (one of ten categories) and functional score (from MDS Section GG). PT payment declines after day 20 of the stay (variable per-diem adjustment).

2. Occupational Therapy (OT): Case-mix based on OT clinical category (same ten categories as PT) and functional score. OT payment declines after day 20.

3. Speech-Language Pathology (SLP): Case-mix based on presence of swallowing disorder, mechanically altered diet, SLP-related comorbidities, and cognitive impairment. No declining adjustment.

4. Nursing: Case-mix based on nursing function score (from MDS), specific services (depression, restorative nursing, intravenous medications, tracheostomy care, isolation), and cognitive function. No declining adjustment.

5. Non-Therapy Ancillaries (NTA): Case-mix based on NTA comorbidity score derived from a list of qualifying conditions (extensive wound care, infection isolation, IV medications, dialysis, oxygen therapy, etc.). NTA payment is high in the first 3 days and declines steeply after day 3.

Plus a non-case-mix base covering room and board and administrative costs.

Clinical Categories (PT and OT)

The ten clinical categories that drive PT and OT case-mix are derived from the primary diagnosis on the qualifying hospital stay:

1. Major Joint Replacement or Spinal Surgery
2. Other Orthopedic
3. Non-Surgical Orthopedic/Musculoskeletal
4. Acute Infections
5. Cardiovascular and Coagulations
6. Pulmonary
7. Medical Management
8. Acute Neurologic
9. Non-Orthopedic Surgery
10. Cancer

MDS Assessment

The Minimum Data Set (MDS) 3.0 is the standardized assessment instrument used in SNFs. Under PDPM:

• 5-day PPS assessment captures most case-mix variables
• Interim Payment Assessment (IPA) is an optional assessment that may be completed if the beneficiary's condition changes significantly
• Discharge assessment is completed at end of Medicare-covered stay

The MDS data drives PDPM case-mix calculation, supports quality reporting under SNF QRP, contributes to SNF VBP measurement, and informs care planning.

Variable Per-Diem Adjustment

PDPM incorporates declining payment factors over the length of stay to recognize that resource use typically decreases over time:

• PT and OT: declining adjustment factor begins after day 20
• NTA: declining adjustment after day 3 (recognizing high front-loaded NTA costs)
• SLP and Nursing: no declining adjustment

Effects of PDPM

Since PDPM implementation in October 2019, observed effects include:

• Reduction in therapy minutes per resident (consistent with PDPM design)
• Some shift in service mix from therapy to skilled nursing
• Increased attention to clinical coding and primary diagnosis selection
• Concerns about therapy access for patients with complex rehabilitation needs (especially as PDPM matures)
• CMS budget-neutrality monitoring and adjustments

SNF Value-Based Purchasing Program (SNF VBP)

Statutory Basis

Section 215 of the Protecting Access to Medicare Act of 2014 created Section 1888(g) and 1888(h) of the Social Security Act, establishing the SNF Value-Based Purchasing Program.

Program Structure

• Performance year + payment year structure
• CMS withholds a percentage of SNF Medicare payments, with a portion returned to facilities based on performance

Current Single Measure (FY 2024 through FY 2026)

The SNF VBP program currently uses a single measure: the SNF 30-Day All-Cause Readmission Measure (SNFRM). The SNFRM measures the risk-adjusted rate of unplanned hospital readmissions within 30 days of SNF admission.

SNF Quality Reporting Program (SNF QRP)

Under the IMPACT Act of 2014 and 42 CFR 483.95, SNFs must report standardized quality data through MDS and claims-based measures. SNFs failing to comply with QRP requirements receive a 2 percentage point reduction in annual payment update. Measures are publicly reported on Medicare.gov Care Compare.

3-Day Stay Waivers

The 3-day qualifying hospital stay requirement is statutory (Section 1861(i)), but waivers are available in certain contexts.

Medicare Shared Savings Program ACO Waiver (ACA Section 3022)

The Medicare Shared Savings Program authority allows ACOs to apply for waiver of the 3-day inpatient hospital stay requirement. Under 42 CFR 425.612:

• ACO must be in MSSP Pathways to Success Enhanced track (or qualifying track)
• ACO must specifically apply for the SNF 3-Day Rule Waiver
• Partner SNFs must be 3-Star or higher on Care Compare
• Beneficiary must be prospectively assigned to the ACO

When the waiver applies, the partner SNF may admit beneficiaries directly from outpatient or observation status without the 3-day inpatient stay. Standard SNF benefit and cost-sharing apply.

Medicare Advantage Waiver

Medicare Advantage plans have broad authority under Section 1852 of the Social Security Act and 42 CFR 422.101(d) to modify cost-sharing and certain coverage rules. Many MA plans waive the 3-day qualifying hospital stay requirement, including D-SNPs (Dual Eligible Special Needs Plans) that serve dual-eligible beneficiaries.

Beneficiaries enrolled in MA plans should review the plan's Evidence of Coverage to determine SNF coverage rules. The MA plan typically has its own preferred SNF network and prior authorization requirements.

COVID-19 PHE Waiver (Expired May 11, 2023)

During the COVID-19 public health emergency, CMS waived the 3-day qualifying hospital stay requirement for all Medicare beneficiaries. This was the only time the waiver applied to fee-for-service Medicare beneficiaries not in MA or an ACO. The waiver ended with the PHE on May 11, 2023.

Discharge Rights and Appeals

When a SNF determines that the beneficiary no longer requires skilled care (or that Medicare will no longer cover the stay), the beneficiary has appeal rights.

Notice of Medicare Non-Coverage (NOMNC)

Before discharging a beneficiary from skilled SNF care, the SNF must issue a Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) at least 2 calendar days before the effective date of coverage termination. The NOMNC informs the beneficiary of:

• The date Medicare coverage will end
• The reason coverage is ending
• The right to a fast-track appeal
• Contact information for the Quality Improvement Organization

Fast-Track Appeal (Expedited QIO Review)

Beneficiaries who disagree with the discharge decision may request an expedited review by the Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO). For Georgia, KEPRO is the BFCC-QIO (1-844-455-8708).

Process:

• Beneficiary must request review by noon of the day before the effective date of coverage termination
• KEPRO reviews medical records and renders a decision within 72 hours
• If KEPRO upholds the discharge, beneficiary is liable for charges after the effective date
• If KEPRO overturns the discharge, Medicare continues to cover the SNF stay

If the beneficiary is unsatisfied with the QIO decision, they may continue to appeal through the ALJ (Administrative Law Judge) level under the standard 5-level Medicare appeals process.

Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN)

The SNF ABN (Form CMS-10055) is issued when the SNF believes Medicare may not pay for specific items or services. The SNF ABN allows the beneficiary to choose whether to receive the services and accept financial responsibility if Medicare denies coverage.

Dual-Eligible SNF Transition to Medicaid Long-Term Care

When a dual-eligible beneficiary exhausts the 100-day Medicare SNF benefit or no longer meets the daily skilled need standard, transition to Medicaid long-term care may preserve coverage.

Georgia Medicaid Nursing Facility Eligibility

• Functional eligibility: Nursing Facility Level of Care (NFLOC), determined by Georgia DCH Aging and Disability Services Division
• Patient pay amount: most income contributed to facility care, with a state-set Personal Needs Allowance and possible spousal allocations
• Medicaid Estate Recovery: may apply after death, subject to hardship waivers and exemptions under Section 1917 SSA

Coordination at the 100-Day Mark

Best practice for SNF social workers and discharge planners:

1. Begin Medicaid LTC application 30 to 45 days before day 100
2. Complete Pre-Admission Screening and Resident Review (PASRR) if applicable
3. Coordinate financial review and resource documentation
4. Communicate with family about expected patient pay amount
5. Confirm facility's Medicaid certification status
6. Ensure continuity of bed (the beneficiary may remain in the same facility if the facility participates in Medicaid)

Georgia SNF Landscape

Major National Chains

National SNF chains operating in Georgia include:

• HCR ManorCare / ProMedica
• Genesis HealthCare
• Consulate Health Care
• Diversicare
• PruittHealth (Georgia-headquartered, multi-state)
• Brookdale Senior Living (selected SNF-certified facilities)
• Five Star Senior Living
• Signature HealthCARE

Hospital-Affiliated SNFs

Many Georgia hospital systems operate or partner with SNFs:

• Emory University Hospital
• Piedmont Healthcare SNF affiliates
• Wellstar SNF affiliates
• Memorial Health (Savannah)
• Augusta University Health
• Northeast Georgia Health System
• Atrium Health Navicent

Regulatory and Resource

• Georgia Department of Community Health (DCH): Medicaid SNF coordination
• Georgia Department of Public Health (DPH): SNF licensing under O.C.G.A. 31-7
• Georgia Healthcare Association (GHCA): state SNF trade association
• Georgia Long-Term Care Ombudsman Program (1-866-552-4464)
• KEPRO Georgia QIO (1-844-455-8708)
• Medicare.gov Care Compare Five-Star Quality Rating publicly reports SNF quality

Worked Examples

Example 1: Margaret, 78, Atlanta, Hip Fracture Post-Acute SNF

Margaret falls at home and sustains a hip fracture. She is taken to Piedmont Atlanta Hospital:

• Admitted as inpatient on May 1
• Surgical repair of hip fracture on May 2
• Hospital stay May 1 through May 4 (4 consecutive inpatient midnights)
• Qualifying 3-day stay met

On May 4, she is discharged to Brookdale Buckhead SNF for post-acute rehabilitation:

• Admitted May 4 (within 30 days of hospital discharge)
• Daily skilled need: PT for gait, transfers, balance, weight-bearing protocol; OT for ADLs; skilled nursing for pain management, incision care, and DVT prophylaxis teaching
• PDPM 5-day assessment: PT clinical category Major Joint Replacement or Spinal Surgery, OT same, SLP no need, Nursing moderate function and services, NTA low

Medicare Part A coverage:

• Days 1-20 (May 4 - May 23): Full Medicare coverage, no daily coinsurance
• Days 21-30 (May 24 - June 2): Daily coinsurance ($217/day FY 2026)
• Margaret's Medicare Supplement Plan G covers the days 21-100 coinsurance

She is discharged home on day 30 (June 2) with home health for continued PT. Total SNF days used in this spell: 30 of 100.

If she is hospitalized later in the year for a new condition, she would still have 70 days available in this spell of illness (as long as the new spell has not been triggered by a 60-day break).

Example 2: Robert, 82, Savannah, Observation Status Disqualifying

Robert falls and is taken to Memorial Health Savannah ER:

• ER evaluation May 1
• Admitted to observation status May 1
• Imaging confirms compression fracture
• Pain management and mobilization in observation May 1, 2
• Physician decides surgery is needed; converts to inpatient May 3
• Surgery May 3
• Hospital discharge May 5
• Inpatient duration: May 3, 4 = 2 consecutive inpatient midnights

Robert's qualifying 3-day stay is NOT met (only 2 inpatient midnights).

His family is informed by the hospital case manager that SNF will not be Medicare-covered. The hospital provided the Medicare Outpatient Observation Notice (MOON) on day 2 of observation, but the family did not fully understand the implications.

Robert needs SNF for rehabilitation. Options:

• Private pay SNF (approximately $300-400 per day in Savannah)
• Long-term care insurance if applicable
• VA benefits if applicable (Robert is a veteran)
• Medicaid LTC if eligible after spend-down

Robert's family consults with the Medicare Rights Center (1-800-333-4114) about appealing the observation status determination. They consult with an elder law attorney about Medicaid spend-down planning. The veteran's benefits coordinator at the Savannah Vet Center is contacted.

After 14 days of private pay SNF, Robert returns home with home health (home health does not require the 3-day qualifying stay).

Example 3: Linda, 75, Macon, Jimmo Maintenance Therapy

Linda has Parkinson's disease. She is hospitalized at Atrium Health Navicent Macon for medication adjustment after worsening symptoms:

• Hospital stay May 1-4 (3 inpatient midnights)
• Qualifying stay met

She is admitted to PruittHealth Macon SNF May 4:

• Daily skilled need: PT for gait/balance/fall prevention, OT for ADLs, skilled nursing for medication management

After 21 days, Linda's improvement plateaus. The SNF therapy director documents that "patient has reached maximum medical improvement; recommend discharge."

Linda's daughter (a retired nurse) recognizes this as the discredited improvement standard. She invokes the Jimmo v. Sebelius Settlement:

• Linda's Parkinson's disease is a progressive condition requiring ongoing skilled assessment
• Maintenance PT continues to require skilled-level care: progression of symptoms, fall risk assessment, adjustment of exercises, safety oversight
• Discharge based on lack of improvement is contrary to the Jimmo standard

Linda's daughter contacts the Atlanta Legal Aid Senior Citizens Law Project (404-377-0701) for support. The advocate provides the SNF with the CMS Jimmo clarification guidance.

The SNF revises its assessment. PT continues with maintenance goals. Linda's care is documented as skilled maintenance therapy: ongoing skilled assessment for falls, adjustment of exercise program as Parkinson's progresses, safety supervision.

She receives 45 days of SNF care (combining initial improvement-focused therapy and maintenance therapy). She is discharged home on day 45 with home health for continued maintenance PT.

Example 4: Charles, 80, Augusta, 100-Day Exhaustion to Medicaid LTC

Charles has an ischemic stroke and is hospitalized at Augusta University Health:

• Acute care stay: 5 inpatient midnights
• Qualifying stay met
• Discharged to PruittHealth Augusta SNF for stroke rehabilitation

PDPM assessment: Acute Neurologic clinical category, high functional impairment, comorbidities including diabetes and hypertension. High initial case-mix.

Medicare SNF coverage:

• Days 1-20: full coverage
• Days 21-100: Charles's Medigap Plan G covers daily coinsurance

At day 75, Charles's social worker initiates Georgia Medicaid LTC application. The application is supported by:

• Medical documentation supporting Nursing Facility Level of Care
• PASRR screening (no mental illness or intellectual disability, so Level I PASRR is sufficient)
• Financial documentation: Social Security $1,800/month, no significant resources (under $2,000)

Medicaid LTC approved effective day 101.

Day 100 (Medicare exhaustion):

• Medicare ends coverage
• Charles remains in PruittHealth Augusta (which is Medicaid-certified)
• Medicaid LTC begins day 101

Patient pay structure:

• Charles's Social Security: $1,800/month
• Personal Needs Allowance: state-set amount (retained by Charles)
• Allowable medical insurance premiums: deducted
• Remainder after allowances: patient pay to facility
• Medicaid pays the difference between patient pay and the Georgia Medicaid NF rate

Charles remains at PruittHealth Augusta for ongoing long-term care. After his death (years later), Medicaid Estate Recovery may apply to recover the cost of his nursing facility care from his estate, subject to hardship waivers (e.g., surviving spouse or disabled child exemption).

Example 5: Patricia, 73, Columbus, D-SNP 3-Day Stay Waiver

Patricia is enrolled in a D-SNP (Dual Eligible Special Needs Plan) in Columbus. She develops cellulitis:

• ER evaluation May 1
• Observation status May 1-2
• Discharged May 2 with oral antibiotics
• Inpatient stay duration: 0 nights (observation only)

A few days later, Patricia's cellulitis progresses. Her D-SNP care manager assesses her at home:

• Patricia requires IV antibiotics
• She lives alone and cannot safely manage IV at home
• Re-hospitalization not clinically required
• D-SNP's MA contract waives the 3-day qualifying hospital stay under 42 CFR 422.101(d)

Patricia is admitted directly to a SNF (a partner SNF in the D-SNP network):

• D-SNP authorizes SNF admission without 3-day stay
• D-SNP covers SNF stay under MA benefits
• D-SNP cost-sharing structure applies (often lower than Original Medicare for D-SNP members)

Patricia receives 10 days of skilled care:

• Skilled nursing for IV antibiotic administration, wound assessment, infection monitoring
• PT to maintain mobility during recovery
• HHA for personal care assistance

She is discharged home on day 10. Home health follow-up and Medicaid Personal Care Services through the Georgia DCH Aging and Disability Services Division continue her care at home.

Example 6: Henry, 85, Athens, MSSP ACO 3-Day Stay Waiver

Henry receives primary care at a practice that participates in a Medicare Shared Savings Program ACO. The ACO is in MSSP Pathways to Success Enhanced Track and has been approved for the SNF 3-Day Rule Waiver under ACA Section 3022. Henry is prospectively assigned to the ACO.

Henry develops urinary tract infection with delirium. Evaluated at the ACO's urgent care:

• Outpatient evaluation
• UTI confirmed
• IV antibiotics initiated
• Family unable to safely manage at home overnight (Henry's wife Eleanor has limited mobility)
• Re-hospitalization not clinically required

Under the ACO 3-Day Rule Waiver, Henry is admitted directly to a partner SNF (a 3-Star or higher facility on Care Compare in the ACO's preferred network) without a 3-day inpatient hospital stay.

Coverage:

• Standard Medicare SNF coverage applies
• Days 1-20 fully covered, no coinsurance
• Henry's Medicare Supplement Plan G would cover days 21-100 coinsurance if needed
• The ACO 3-day waiver does not change the cost-sharing structure

Henry receives 7 days of SNF care:

• Skilled nursing for IV antibiotic completion
• Skilled nursing for delirium assessment and monitoring
• PT to maintain mobility during recovery
• HHA for personal care

He is discharged home on day 7. The ACO care manager coordinates home health follow-up and ensures medication reconciliation.

The ACO's quality measures (including SNF readmission rates) and total cost of care benchmarks include this episode, supporting the ACO's value-based care performance.

Common Mistakes

1. Believing observation status counts toward the 3-day qualifying stay. Only inpatient status counts. The Two-Midnight Rule and the NOTICE Act / MOON disclosure address this issue but do not change the underlying rule.

2. Believing the 100-day benefit is annual. The 100-day benefit is per spell of illness. The benefit resets only after the beneficiary has been out of the hospital and out of skilled SNF care for 60 consecutive days.

3. Believing improvement potential is required for skilled coverage. Jimmo v. Sebelius clarified that maintenance therapy is covered if skilled-level care is required. Improvement is NOT required. The Jimmo standard applies in SNF, home health, and outpatient therapy.

4. Believing Medicare covers long-term custodial care in a SNF. Medicare covers skilled care, not custodial care. Long-term custodial care is covered by Medicaid LTC (after eligibility), long-term care insurance, or private pay.

5. Believing SNF daily coinsurance applies from day 1. Days 1 through 20 are full Medicare coverage with no coinsurance. Coinsurance applies days 21 through 100.

6. Believing the 3-day stay requirement always applies. MSSP ACO waivers (under ACA Section 3022), Medicare Advantage waivers (under 42 CFR 422.101(d)), and historically the COVID-19 PHE waiver provide exceptions.

7. Confusing "skilled nursing facility" (SNF, Medicare post-acute) with "nursing facility" (NF, Medicaid LTC). SNF specifically refers to Medicare post-acute coverage. Many of the same physical facilities provide both SNF and NF care; the financial coverage source is the distinction.

8. Believing the 30-day window between hospital and SNF admission cannot be exceeded. Limited medical exception allows admission beyond 30 days if SNF admission would not have been appropriate within 30 days but would have been appropriate at the time of hospital discharge.

9. Missing the NOMNC fast-track appeal deadline. Beneficiaries have only until noon of the day before coverage termination to request expedited QIO review. Late requests forfeit the fast-track right.

10. Misunderstanding PDPM case-mix. PDPM uses five case-mix components based on patient characteristics and primary diagnosis. Therapy volume does NOT drive PDPM payment (unlike the prior RUG-IV system).

11. Believing dental, hearing, and vision are covered in SNF. Medicare SNF coverage does not include routine dental, hearing, or vision care. Some Medicare Advantage plans cover these as supplemental benefits.

12. Believing prescription drugs are paid by Part D during the SNF stay. During the Medicare-covered SNF stay, drugs are covered by the SNF as part of the per-diem (Part A SNF coverage). Part D resumes coverage after the SNF discharge for self-administered drugs.

13. Believing physician services in the SNF are covered under Part A. Physician services in the SNF are covered under Part B (with standard 20% coinsurance), separate from the Part A SNF per-diem payment.

14. Failing to coordinate Medicare and Medicaid at day 100. Medicaid LTC application should begin 30 to 45 days before day 100 to ensure continuity of coverage. Last-minute application risks gap in coverage.

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What is the Medicare Skilled Nursing Facility (SNF) Benefit?

The Medicare SNF Benefit is a Medicare Part A entitlement established by Section 1812(a)(2) of the Social Security Act. It covers up to 100 days of post-acute skilled nursing facility care per spell of illness, following a qualifying inpatient hospital stay of at least 3 consecutive days. The benefit is designed for short-term skilled care after a hospital admission, not for long-term custodial care.

What is the 3-day qualifying hospital stay?

Under Section 1861(i) of the Social Security Act, the beneficiary must have been a hospital inpatient for at least 3 consecutive days within 30 days before SNF admission. The 3 days must be inpatient status (not observation). The day of admission counts; the day of discharge does not count.

How does the spell of illness work?

A spell of illness begins on the first day of inpatient hospital or skilled SNF care. It ends after 60 consecutive days during which the beneficiary has not been in a hospital and has not received skilled SNF care. After a 60-day break, a new spell of illness begins with a fresh 100-day SNF benefit.

What is the Jimmo v. Sebelius settlement?

Jimmo v. Sebelius (January 24, 2013) was a federal court settlement clarifying that Medicare coverage of skilled services does NOT require improvement potential. Maintenance therapy is covered if the services require skilled level of care. This rejected a long-applied unwritten "improvement standard" that had been denying coverage for chronic conditions.

What is the Patient-Driven Payment Model (PDPM)?

PDPM is the SNF payment model effective October 1, 2019, replacing the prior Resource Utilization Group (RUG-IV) system. PDPM uses five case-mix components based on patient characteristics (PT, OT, SLP, Nursing, Non-Therapy Ancillaries) rather than therapy volume. PDPM eliminated therapy minutes as the primary payment driver. :::

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Talk to Someone About Medicare SNF Coverage in Georgia

If you are considering Medicare SNF care for yourself or a family member in Georgia, or if you have questions about coverage, the 3-day qualifying stay, daily skilled need, the 100-day benefit, or discharge appeals, these organizations can help.

Government Programs and Direct Services

• Georgia Department of Community Health Medicaid Member Services: 1-866-211-0950
• Medicare: 1-800-MEDICARE (1-800-633-4227); TTY 1-877-486-2048
• KEPRO (Georgia Quality Improvement Organization): 1-844-455-8708 (for SNF fast-track discharge appeals)
• GeorgiaCares (Georgia SHIP and LTC Ombudsman): 1-866-552-4464 (free Medicare counseling and long-term care advocacy)
• Social Security Administration: 1-800-772-1213

Federal Oversight and Civil Rights

• HHS Office of Civil Rights: 1-800-368-1019
• HHS Office of Inspector General: 1-800-447-8477 (SNF fraud or abuse reporting)
• CMS National Hotline: 1-800-MEDICARE

Beneficiary Advocacy

• Medicare Rights Center: 1-800-333-4114 (especially for observation status appeals)
• Center for Medicare Advocacy: 1-860-456-7790 (Jimmo enforcement and complex appeals)
• Eldercare Locator: 1-800-677-1116

Georgia Resources

• Georgia Healthcare Association (state SNF trade association)
• Georgia Department of Public Health (SNF licensing)

Legal Assistance

• Atlanta Legal Aid Senior Citizens Law Project: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469
• 211 Georgia (general social services referrals): dial 211

Veterans

• VA Caregiver Support Line: 1-855-260-3274

About Brevy

Brevy is building America's most trustworthy, comprehensive, and up-to-date online resource on eldercare. This guide is one of an ongoing series on Georgia Medicare and Medicaid topics published on brevy.com. Information is current as of May 2026 and is provided for educational purposes. The Medicare Skilled Nursing Facility Benefit is a federal benefit governed by the Social Security Act and the regulations at 42 CFR Parts 409, 413, 424, and 483, and operates the same in Georgia as in every state. SNF coverage, eligibility, and care planning should be discussed with a Medicare-certified SNF, your physicians, and qualified counsel. This guide is educational and does not constitute medical, legal, or financial advice.

Find personalized help navigating Medicare SNF coverage in Georgia at brevy.com. :::