Georgia Medicare Skilled Nursing Facility (SNF) Benefit

In 2026, Original Medicare covers up to 100 days of skilled nursing facility (SNF) care per benefit period, but only after a 3-day inpatient hospital stay. That coverage lasts only while you still need daily skilled care: days 1 through 20 cost you nothing after the Part A hospital deductible, days 21 through 100 carry a coinsurance of $217 a day, and after day 100 Medicare pays nothing.1

This guide focuses on what happens when you have both Medicare and Georgia Medicaid, or are heading toward it, where the coinsurance, the 3-day rule, and the day-100 cliff work differently.

What Medicare's Skilled Nursing Facility Benefit Covers in Georgia

Medicare's skilled nursing facility benefit is a Part A entitlement for short-term, post-acute skilled care, not for a long-term nursing home stay. Three things must all be true: a qualifying inpatient hospital stay of at least 3 consecutive days, admission to a Medicare-certified SNF (generally within 30 days of leaving the hospital) for care related to that stay, and a daily need for skilled services. Then Medicare covers up to 100 days per benefit period on this cost ladder. You do not need a second 3-day stay to come back: re-enter a SNF, or resume skilled care after stopping it, within 30 days and the days left in that benefit period are still yours.1

Across all 80 days that is about $17,360 out of pocket if nothing else covers it.1,2

The benefit period (not a calendar year)

The 100 days are counted per benefit period, not per year, and many people believe otherwise. A benefit period begins the day you are admitted to a hospital or SNF as an inpatient and ends only after 60 days in a row with no inpatient hospital care and no skilled SNF care; only then does a fresh 100-day allowance begin. The clock can run without leaving the building: dropping from skilled to custodial care can start a new period. More than one benefit period can fall in a calendar year, each with its own Part A deductible.2 But exhaust the 100 days, get re-hospitalized a month later, and there is no fresh 100. That is usually when a family turns to Georgia Medicaid long-term care.

The 3-Day Qualifying Hospital Stay and the Observation Trap

This requirement trips up many Georgia families. Medicare covers SNF care only after at least 3 consecutive days as a hospital inpatient, counting the admission day but not the discharge day.5

The trap is observation status: it is billed as an outpatient service even when you spend several nights in a hospital bed, so those nights do not count. A patient who spends three midnights in observation and is then sent to a SNF has no qualifying stay, and the claim is denied.5

Two protections exist. Under the Two-Midnight Rule, inpatient admission is generally appropriate when the physician expects care to span at least two midnights. And a hospital must give you a Medicare Outpatient Observation Notice (MOON) once you are under observation as an outpatient for more than 24 hours, no later than 36 hours in, so you learn your status while you can still question it.5

If your status is switched from inpatient to outpatient during the stay, you may be able to appeal, a right CMS created after Alexander v. Azar. A switch made on or after February 14, 2025 puts you on the prospective "fast" appeal track: you should get a Medicare Change of Status Notice (CMS-10868) before you leave, and you or your representative can request the appeal through Georgia's BFCC-QIO, though the hospital or SNF that provided the care cannot act as your representative. Filing from the hospital is fastest, but the track stays open after discharge: you can still ask for an appeal once you are home, following that notice's instructions, or by contacting your local BFCC-QIO if you cannot find it.6 Winning is not a blank check: a fast appeal decided in your favor leaves you owing the Part A inpatient deductible, and it makes you eligible for a Medicare-covered SNF stay within 30 days of discharge only if the other coverage rules are also met. The separate retrospective track, for stays admitted before February 14, 2025, closed to new filings on January 2, 2026; a later request is denied unless you show good cause: a valid reason, beyond your control, acted on as soon as the circumstances resolved. Where such an appeal succeeds and covered SNF services were included in it, the SNF must refund what you paid, generally within 60 days.6 GeorgiaCares helps with this free.

Does Improvement Matter? The Jimmo Standard

A SNF cannot cut off your Medicare coverage because you have stopped improving. Under the Jimmo v. Sebelius settlement, coverage of skilled nursing and skilled therapy turns on your need for skilled care, not on whether you are expected to get better. Skilled care to maintain your condition, or to prevent or slow a decline, is covered when a professional's skills are needed to deliver it safely.7

The same Jimmo maintenance standard applies across skilled nursing facility, home health, and outpatient therapy care, and matters most for Georgians with Parkinson's, multiple sclerosis, or lingering deficits after a stroke. It does not suspend the rest of the rules: care must still be reasonable and necessary, and the 3-day qualifying stay still applies.7 See our guide to the Jimmo settlement and maintenance therapy in Georgia.

Who Pays the $217-a-Day Coinsurance if You Have Medicaid?

For most Georgians in Original Medicare, days 21 through 100 mean $217 a day out of pocket unless something else covers it. Two things commonly do.1

A Medicare Supplement (Medigap) policy can pay the SNF coinsurance, depending on your plan letter. Plan G pays the skilled nursing facility care coinsurance in full, which is why a Georgian with Plan G rarely sees a SNF bill for days 21 through 100.4 Because Medigap is standardized by letter, every policy under the same letter carries the same basic benefits whichever insurer sold it.8 So check your letter.

The bigger story for dual eligibles is the Medicare Savings Program. If you qualify as a Qualified Medicare Beneficiary (QMB) through Georgia Medicaid, QMB pays your Part A and Part B premiums and all Medicare cost-sharing (deductibles, coinsurance, copays), which is what picks up the SNF coinsurance. Federal law also bars providers from balance-billing a QMB enrollee for it.3 In 2026, Georgia applies the federal QMB limits: monthly income up to $1,350 for an individual or $1,824 for a couple, with a resource limit of $9,950 for an individual and $14,910 for a couple. The Specified Low-Income Medicare Beneficiary (SLMB) program covers income up to $1,616 individual or $2,184 couple, and the Qualifying Individual (QI) program up to $1,816 individual or $2,455 couple, though SLMB and QI pay only the Part B premium, not the SNF coinsurance.3 Both are still worth applying for: QMB, SLMB, and QI each automatically qualify you for Part D Extra Help, which pays drug costs, not the SNF coinsurance.3

Georgia processes these through the Division of Family and Children Services; apply via Georgia Gateway or by calling 1-877-423-4746.3 If you are close to the limits, apply anyway; the Georgia Medicare Savings Programs guide walks through it.9

If your Medicare comes through a Medicare Advantage plan, the math changes again. MA plans, including the Dual Eligible Special Needs Plans (D-SNPs) built for people with both Medicare and Medicaid,10 must cover every medically necessary Part A and Part B service except hospice, which Original Medicare keeps covering, but they set their own cost-sharing rather than the standard $217-a-day schedule, most require in-network providers, and many require prior authorization for a SNF admission. That network rule has a floor: emergency care, out-of-area urgent care, and temporary out-of-area dialysis are covered either way.11 QMB cost-sharing protection still applies to you inside a plan,3 but the plan sets the network and approval terms, so confirm its SNF cost-sharing and preferred facilities before day 21.

What Happens at Day 100: The Georgia Medicaid Handoff

Medicare's SNF benefit ends at day 100, or earlier if you no longer need daily skilled care. If the need is now custodial, Medicare does not cover it, and for many Georgia families the next payer is Georgia Medicaid long-term care.1

Georgia Medicaid can pay for a nursing facility stay if the person meets both a functional and a financial test. Functionally, they must need a Nursing Facility Level of Care, determined through the Georgia Department of Community Health. Financially, Georgia is an income-cap state: the institutional Medicaid income limit is 300% of the federal Supplemental Security Income benefit rate, or $2,982 a month for an individual and $5,964 for a couple in 2026, with a countable-asset limit of $2,000 individual and $3,000 couple. That $3,000 is not the ceiling when only one spouse enters the facility: Georgia's own Appendix A1 sets the resource limit for an applicant with a spouse still at home at $162,660 + $2,000, or $164,660.12

An applicant whose income is at or above that cap can still qualify by sheltering the excess in a Miller Trust, Georgia's Qualified Income Trust. It must be irrevocable, and whatever remains at the applicant's death goes to the Department of Community Health, up to what Medicaid spent on their care.12

Once approved, the resident keeps a Personal Needs Allowance and contributes the rest of their income toward care as their patient liability. In Georgia that nursing-facility allowance is $70 a month, the figure DFCS has carried since July 2019 and still shows for 2026. A separate $90 allowance applies to a VA pensioner or surviving spouse in a nursing home who has no dependents, but it is not a windfall: the VA check for those residents is reduced to the amount of the allowance regardless of their other income. A VA pensioner who does have dependents keeps the same $70.13

The $70 is not the only carve-out. Federal post-eligibility rules also require deductions for a monthly maintenance needs allowance for a spouse still at home, allowances for dependents or family, health-insurance premiums including Medicare premiums, deductibles and coinsurance, and necessary medical care the state plan does not cover. So a married applicant whose spouse remains at home does not hand over everything above $70; run the patient-liability budget with DFCS rather than assuming.13 After the resident's death, Georgia Medicaid may seek to recover the cost of that care from their estate, subject to exemptions; see Georgia Medicaid estate recovery.

Your Georgia Medicare Skilled Nursing Facility Benefit Is Not a Medicaid Nursing Home

The words sound the same, which is why families conflate them. A Medicare skilled nursing facility stay is short-term skilled care after a hospital admission. A Georgia Medicaid nursing home stay is long-term custodial care: routine help with bathing, dressing, toileting, and medication once the skilled need is gone, which Medicare will not pay for. One building often holds both kinds of bed, so the difference is not the place, it is who is paying.1

3-Day Stay Waivers: D-SNPs and ACOs in Georgia

The 3-day inpatient requirement is not absolute. Two arrangements can waive it, and both are relevant to Georgia dual eligibles.

Some Medicare Advantage plans, including D-SNPs, waive the 3-day qualifying stay and can authorize a SNF admission directly. Waiving it is a plan choice, not a feature every plan carries, so read your own plan's benefit documents rather than assume.1

Which D-SNPs are available differs by county. Georgia's Department of Community Health announced a moratorium on contracting with any new D-SNPs from August 1, 2025, to comply with the federal D-SNP integration requirements at 42 CFR 422.514(h), with further updates to follow.10 To see what is offered in your county this plan year, use the Medicare Plan Finder or call GeorgiaCares; our Georgia D-SNP guide explains how these plans work.

Separately, providers in a Medicare Shared Savings Program Accountable Care Organization can hold a SNF 3-Day Rule Waiver, letting an assigned patient enter a partner SNF without the inpatient stay.1 Standard Medicare SNF cost-sharing still applies in both cases.

Worked Examples

The scenarios below are hypothetical and illustrative. Every situation is different; confirm your own coverage with the SNF, your plan, and Georgia Medicaid.

Example 1: A qualifying stay and a Medigap plan

Margaret, 78, in Atlanta, fractures her hip and stays four consecutive inpatient midnights, so her qualifying stay is met. She transfers to a SNF needing daily physical therapy and skilled nursing. Medicare covers days 1 through 20 at $0 a day, the Part A deductible already paid for her hospital stay. For days 21 through 30 the coinsurance is $217 a day, but her Medigap Plan G pays it, so she owes nothing.1 She goes home on day 30 with 70 SNF days left in the period.

Example 2: Observation status denies the benefit

Robert, 82, in Savannah, spends two nights under observation for a compression fracture, then one inpatient night after a procedure. His inpatient stay is a single midnight, so his qualifying stay is not met even though he was in the hospital three days, and the SNF he needs will not be Medicare-covered. His family requests the MOON and calls GeorgiaCares while weighing private pay against Medicaid.5

Example 3: Running out at day 100 and pivoting to Georgia Medicaid

Charles, 80, in Augusta, has a stroke and still needs facility care as day 100 approaches. At day 75 the SNF social worker starts his Georgia Medicaid long-term-care application. His income is below the $2,982 cap and his assets are under $2,000, so he is approved effective day 101. He is widowed with no dependents, so nothing is deducted for a spouse at home: he keeps the $70 monthly Personal Needs Allowance and his Medicare premiums, and the rest of his income goes toward care. His facility is Medicaid-certified, so he stays in the same bed.12,13

Discharge Rights and Fast Appeals

Before a SNF ends your Medicare-covered stay it must give you a Notice of Medicare Non-Coverage at least 2 days before covered services end. If you disagree, ask your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for an expedited review, following the notice's instructions no later than noon the day before the termination date printed on it.14 In Georgia the BFCC-QIO is Acentra Health (formerly Kepro), at 1-888-317-0751; you can confirm it through the CMS BFCC-QIO page or 1-800-MEDICARE. Missing that noon deadline is not the end of the road: you can still ask the BFCC-QIO to review the case, though different rules and time frames apply and you may be liable for care after the original termination date.15 If the review upholds the discharge, the standard Medicare appeals levels remain open.

Statutory and Regulatory Reference

The Medicare SNF benefit rests on the Social Security Act: Section 1812(a)(2) establishes post-hospital extended care as a Part A benefit, Section 1861(i) defines extended care services and the qualifying-stay requirement, and Section 1812(b)(2) sets the 100-day limit per benefit period. Coverage rules are codified at 42 CFR 409.20 through 409.36; facility conditions of participation at 42 CFR Part 483. Custodial care that outlasts the benefit falls to Medicaid.

Where to Get Help in Georgia

Learn More

Find personalized help navigating Medicare SNF coverage and the Medicaid handoff in Georgia at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.