Georgia Medicare SNF PPS Guide (2026)

For most Georgia families, the Medicare Skilled Nursing Facility benefit shows up at a moment no one planned for. A parent is admitted to the hospital after a fall, a stroke, or pneumonia. After three or four days of inpatient care, the hospital case manager mentions that the discharge plan is a SNF, often called a "rehab" or "nursing home" in everyday conversation. Within a day or two the parent is transferred, and a 100-day clock starts running. Medicare's Skilled Nursing Facility Prospective Payment System (SNF PPS) pays the facility for the first twenty days in full. From day 21 through day 100, the beneficiary owes a daily coinsurance set each year by CMS (for 2026, $217 per day per the CMS 2026 Medicare deductible and coinsurance notice). After day 100, if the beneficiary still needs care, Medicare's role ends and the family must figure out the next step.

This guide explains how Medicare pays skilled nursing facilities under SNF PPS, the rules that determine when Medicare will pay for SNF care, what coverage actually covers, what the beneficiary owes, and how to choose a SNF in Georgia. It also explains the framework that providers, hospital discharge planners, and SNF administrators operate under, because understanding the framework is the only way to understand why coverage decisions are made and how to appeal them when something goes wrong.

SNF PPS was authorized by Section 4432 of the Balanced Budget Act of 1997 and replaced the cost-based reimbursement system that previously paid SNFs based on their actual costs of care with a federal per diem payment methodology under Section 1888(e) of the Social Security Act. The initial framework used a case-mix classification called Resource Utilization Groups (RUG-IV), which paid SNFs based primarily on therapy minutes delivered. The Patient Driven Payment Model (PDPM) succeeded RUG-IV and pays SNFs based on patient clinical characteristics across five components: Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Non-Therapy Ancillary services.

For Georgia, the SNF landscape includes Medicare-certified skilled nursing facilities serving Medicare beneficiaries across urban, suburban, and rural counties. Major Georgia-based operator PruittHealth has substantial presence, particularly in South Georgia. National operators including Genesis HealthCare and SavaSeniorCare operate Georgia facilities. Many independent and small-chain SNFs serve rural communities where they are the primary post-acute resource. The Georgia Department of Community Health, through its Healthcare Facility Regulation Division, conducts annual recertification surveys, complaint investigations, and enforcement actions. The Georgia State Long-Term Care Ombudsman provides advocacy for residents and families.

This guide is published by Brevy at brevy.com as part of our mission to be the most trusted eldercare resource in America. It covers SNF PPS, the PDPM methodology and its five components, the MDS 3.0 patient assessment, the three-day qualifying hospital stay requirement, the 100-day spell of illness maximum, the days 21-100 coinsurance, the SNF Quality Reporting Program, the SNF Value-Based Purchasing program, the Five-Star Quality Rating, the Conditions of Participation under 42 CFR Part 483 Subpart B, the OBRA 1987 Nursing Home Reform Act, the consolidated billing rules, the coordination with Medicaid long-term care for dual-eligible residents, the Georgia regulatory environment, and the practical questions that Georgia families face. The guide concludes with worked examples, frequently asked questions, common pitfalls, and a list of resources Georgia families can use to navigate SNF care.

1. Medicare beneficiaries qualify for SNF coverage only after a three-day qualifying inpatient hospital stay. The three days must be consecutive midnights spent as an inpatient. Observation status does NOT count toward the three-day requirement, and this distinction is a frequent source of unexpected coverage denials. The SNF admission must occur within 30 days of hospital discharge, with limited exceptions.

2. The Patient Driven Payment Model (PDPM) is the current case-mix classification system. PDPM pays SNFs based on patient clinical characteristics across five components: Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Non-Therapy Ancillary services. PDPM replaced the prior RUG-IV framework that paid based primarily on therapy minutes.

3. Medicare SNF coverage is limited to 100 days per spell of illness. A new spell of illness begins after the beneficiary has been out of a hospital or SNF for 60 consecutive days. The 100-day maximum applies whether the days are continuous or interrupted within the same spell.

4. Beneficiary cost-sharing for SNF care is tiered. Days 1-20 of each spell have no coinsurance (Medicare pays in full). Days 21-100 carry a daily coinsurance set annually by CMS (for 2026, $217 per day per the CMS 2026 deductible and coinsurance notice). After day 100, Medicare coverage ends and the beneficiary is responsible for 100 percent of SNF costs.

5. Coverage requires daily skilled services. Medicare pays for SNF care only when the beneficiary needs daily skilled nursing or rehabilitation services that can be provided only by or under the supervision of skilled personnel. Custodial care alone, even if the beneficiary needs help with activities of daily living, does not qualify. Maintenance therapy can qualify under the Jimmo v. Sebelius standard.

Why this matters in Georgia in 2026

Before the technical mechanics, consider the practical situation that brings most Georgia families into contact with the SNF system. A loved one (often a parent in their 70s or 80s, sometimes a younger family member after a major illness or surgery) has been hospitalized. The reason for admission varies: stroke, heart attack, hip fracture from a fall, pneumonia, sepsis, surgical complication. After several days of inpatient care, the patient is medically stable enough to leave the hospital but not well enough to go home safely. The hospital case manager raises the possibility of post-acute care, and the family is presented with options: SNF, inpatient rehabilitation facility (IRF), home health, or, in some cases, hospice.

The right choice depends on factors that are not always obvious to families in the middle of a hospital crisis. SNF care offers daily skilled nursing and therapy in a residential setting. It is appropriate for patients who need substantial nursing or rehabilitation but cannot tolerate the more intensive IRF setting (which requires three hours of therapy daily). It is appropriate for patients whose home environment cannot support recovery, whose family cannot provide adequate care, or whose clinical needs require nursing supervision. It is appropriate for patients whose recovery trajectory needs more time than the typical home health benefit can accommodate.

But the SNF PPS system has rules that often surprise families. The three-day qualifying hospital stay must be inpatient, not observation, and many Georgia hospitals admit patients to observation status rather than inpatient for specific medical conditions. If the patient is in observation rather than inpatient, the SNF will not be Medicare-covered even though the patient is clinically appropriate for SNF care. The 100-day maximum runs out faster than families expect when daily skilled services continue throughout the stay. The day 21 coinsurance, $217 per day in 2026, equals more than $1,500 per week and over $6,500 per month, a substantial cost burden for many families.

For Georgia families, several additional dimensions matter. Georgia has not expanded Medicaid, which means that some families face a longer path to Medicaid long-term care coverage when Medicare SNF benefits exhaust. The Georgia long-term care Medicaid eligibility process can take months, and families may need to navigate the spousal impoverishment provisions of Section 1924 of the Social Security Act, the estate recovery provisions of Section 1917(b), and the asset spend-down requirements that govern Medicaid eligibility. Brevy publishes this guide and related guides at brevy.com to help Georgia families understand the framework before the crisis hits.

What SNF PPS replaced: the pre-PPS cost-based framework

To understand what SNF PPS changed, it helps to start with what existed before. From the inception of Medicare through the late 1990s, Medicare paid skilled nursing facilities under a cost-based reimbursement framework. Each SNF filed an annual cost report with its Medicare fiscal intermediary, the cost report identified the facility's actual Medicare-related costs for the year, and Medicare reimbursed the facility based on those costs, subject to upper limits and various cost report rules.

Cost-based reimbursement had certain advantages. It ensured that facilities received payment commensurate with their actual costs, which kept low-margin operations financially viable. It supported high-cost residents (those with complex medical needs) because higher costs translated into higher payments. It avoided the risk that a fixed payment would systematically underpay for resource-intensive residents.

But cost-based reimbursement had significant disadvantages that drove the move to prospective payment. It created weak incentives for efficiency, since higher costs led to higher payments. It produced enormous variability in payments across similar facilities depending on cost accounting methods. It required substantial administrative effort for cost report preparation, audit, and settlement. And it provided no clear signal about whether the federal government was paying appropriately for the care actually delivered.

By the mid-1990s, Medicare SNF spending was growing rapidly, and the perceived inadequacy of cost-based reimbursement was a major contributor. The Balanced Budget Act of 1997 included Section 4432, which established the SNF PPS framework. The initial implementation used the Resource Utilization Groups (RUG-III, later RUG-IV) classification system, which paid SNFs based on case-mix categories that reflected primarily therapy minutes delivered and certain nursing characteristics.

RUG-IV: the original SNF PPS case-mix framework

Under the original SNF PPS framework, Medicare paid SNFs using the RUG-IV case-mix classification system. RUG-IV used a hierarchy of categories that classified each patient day based primarily on therapy minutes and clinical characteristics. The categories included Ultra High, Very High, High, Medium, and Low rehabilitation groups, plus Extensive Services, Special Care, Clinically Complex, Behavior and Cognitive Impairments, and Reduced Physical Function categories for non-rehabilitation patients.

RUG-IV had specific implementation features that shaped SNF behavior. The therapy-minute thresholds created strong incentives for SNFs to deliver therapy minutes that put residents into higher-paying categories; consult the historical CMS RUG-IV documentation for the precise weekly-minute cutpoints. Critics argued that the framework rewarded therapy volume rather than therapy effectiveness, and that some facilities delivered marginally beneficial therapy to capture higher payments.

By the mid-2010s, RUG-IV had become controversial. The HHS Office of Inspector General, MedPAC, and CMS itself raised concerns about therapy-driven payment patterns. The IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation Act) directed CMS to develop a unified case-mix classification system for post-acute care that would be less dependent on therapy minutes. The result, after several years of development and rulemaking, was PDPM.

The Patient Driven Payment Model (PDPM) under SNF PPS

The Patient Driven Payment Model replaced RUG-IV as the case-mix classification methodology within SNF PPS. PDPM pays SNFs based on patient clinical characteristics rather than therapy minutes. The five components are Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Non-Therapy Ancillary services. Each component has its own per diem rate determined by the patient's classification within that component.

Physical Therapy (PT) component

The PT component is determined by the patient's clinical category (such as Major Joint Replacement, Orthopedic Other, Acute Neurologic, Non-Orthopedic Surgery, or Medical Management) combined with a function score derived from Section GG of the MDS. Section GG captures the patient's functional abilities in self-care and mobility, scored at admission and discharge. The combined clinical category and function score yields the PT case-mix group, which determines the PT per diem rate.

Occupational Therapy (OT) component

The OT component follows similar logic to PT. The patient's clinical category combined with a function score yields the OT case-mix group, which determines the OT per diem rate. Although PT and OT use the same clinical categories and the same function score, they are scored separately and produce separate per diem rates.

Speech-Language Pathology (SLP) component

The SLP component is determined by three factors: the patient's clinical category, presence of a mechanically altered diet, and presence of specific SLP-related comorbidities (such as aphasia, dysphagia, or cognitive impairment). The combination yields the SLP case-mix group and per diem rate.

Nursing component

The Nursing component is the most clinically driven component. The patient's MDS data is processed through a series of decision rules that classify the patient into a PDPM nursing group, organized into broader categories such as Special Care High, Special Care Low, Clinically Complex, Behavioral Symptoms and Cognitive Performance, and Reduced Physical Function. The patient's function score contributes to the nursing classification.

Non-Therapy Ancillary (NTA) component

The NTA component captures the patient's comorbidity burden using a scoring system that assigns points for specific conditions (such as morbid obesity, asthma, diabetes mellitus with chronic kidney disease, multiple sclerosis, parenteral feeding, IV medications, and many others). The total NTA score determines the patient's NTA case-mix group and per diem rate.

Variable per diem adjustments

PDPM includes variable per diem adjustments that reflect typical resource use patterns over the SNF stay. The PT and OT per diem rates decline modestly as the stay progresses, reflecting that therapy intensity typically decreases over a typical SNF stay. The NTA per diem is front-loaded, with higher rates early in the stay and lower rates thereafter, reflecting that pharmacy and ancillary use is typically highest early in the stay. The SLP and Nursing rates are constant across the stay. Consult the current Medicare SNF PPS Final Rule for the operative variable-per-diem schedule.

Total per diem calculation

A patient's total daily payment under PDPM is the sum of the PT, OT, SLP, Nursing, and NTA per diem rates (each adjusted for the case-mix group within that component), with the variable per diem adjustments applied where applicable. The total is multiplied by a wage index and an annual market basket factor to produce the SNF's final per diem payment for that patient on that day.

The Minimum Data Set (MDS) 3.0

The Minimum Data Set (MDS) 3.0 is the patient assessment instrument that drives PDPM classification. SNFs complete MDS assessments at multiple points during each Medicare-covered stay, and the data captured in the MDS determines the patient's PDPM case-mix groups, which in turn determine the per diem payment.

Assessment schedule

The MDS assessment schedule for a Medicare-covered SNF stay typically includes:

• 5-day assessment: completed by day 5 of the stay, captures admission clinical characteristics, drives the initial PDPM classification
• Interim Payment Assessment (IPA): optional, completed at significant clinical change, allows PDPM reclassification mid-stay
• Discharge assessment: completed at end of Medicare Part A stay, captures discharge function and outcomes

The MDS schedule under PDPM is simpler than the schedule under RUG-IV, which required assessments at multiple points to capture changing therapy intensity.

MDS data elements

The MDS captures information across many sections. Key sections that drive PDPM include:

• Section A: Identification and admission data
• Section C: Cognitive Patterns (BIMS or staff assessment)
• Section GG: Functional Abilities (self-care and mobility, current)
• Section I: Active Disease Diagnosis (ICD-10 coded)
• Section J: Health Conditions (including specific conditions for SLP component)
• Section K: Swallowing and Nutritional Status (including mechanically altered diet)
• Section N: Medications (counts of specific medication types for NTA scoring)
• Section O: Special Treatments (for NTA scoring and other purposes)

MDS coding accuracy

PDPM has placed substantial emphasis on accurate MDS coding. The five-component classification depends on data captured across many MDS items, and coding errors can result in either over-payment (if items are coded that do not actually apply) or under-payment (if applicable items are missed). MDS coordinators in SNFs must understand both the clinical reality of the patient and the precise definitions and rules in the MDS Resident Assessment Instrument User Manual.

MDS audit

The Medicare Administrative Contractor (Palmetto GBA for Georgia) and the HHS Office of Inspector General conduct MDS audits to verify coding accuracy. Audit findings can result in payment recovery, civil money penalties, and in serious cases referral for fraud investigation.

Coverage requirements: when Medicare pays for SNF care

Not every SNF admission is Medicare-covered. The Medicare SNF benefit has specific coverage requirements that must all be met. When any requirement is not met, the SNF stay (or portions of it) is not Medicare-covered, and the beneficiary or family is responsible for payment.

The three-day qualifying hospital stay

The beneficiary must have been hospitalized as an inpatient for at least three consecutive midnights immediately preceding the SNF admission. Refer to the current CMS Medicare Benefit Policy Manual for the operative regulatory text.

The three-day rule is the most frequent source of unexpected coverage denials. Specifically, observation status does NOT count toward the three-day requirement. A patient who spends two midnights in observation and then is admitted as an inpatient for one midnight has not met the three-day requirement, even though she has been in the hospital for three midnights total. Hospital case managers and discharge planners should communicate clearly with families about the patient's inpatient versus observation status during the hospital stay.

Some specific exceptions and variations apply:

• Medicare Advantage plans may waive the three-day requirement (and many do)
• Certain ACOs and APMs participating in qualifying waiver programs may admit directly without a three-day stay
• The COVID-19 Public Health Emergency waiver of the three-day rule has expired
• The day of discharge does not count toward the three-day requirement

Within 30 days of hospital discharge

The SNF admission must generally occur within 30 days of hospital discharge. Limited exceptions apply when admission within 30 days was medically inappropriate. For example, if a patient is not yet able to benefit from skilled care because of ongoing acute issues but becomes able later, an admission beyond 30 days may still qualify.

Daily skilled services

The patient must need daily skilled nursing or rehabilitation services that can be provided only by or under the supervision of skilled personnel. Skilled services include:

• Skilled nursing observation and assessment
• Wound care
• IV therapy
• Tube feeding administration and management
• Physical therapy, occupational therapy, or speech-language pathology
• Medication management for complex regimens
• Skilled teaching

The Jimmo v. Sebelius settlement clarified that maintenance therapy can qualify as skilled when the maintenance is needed to prevent decline, even if the patient is not improving. This standard rejected the prior improvement standard that had sometimes been applied incorrectly.

Custodial care alone (assistance with bathing, dressing, eating, transferring) does not qualify as skilled care, regardless of how much assistance the patient needs. A patient who needs only custodial care must seek alternative payment (private pay, Medicaid long-term care, or long-term care insurance).

Physician certification

A physician must certify that the patient requires skilled care and must establish a plan of care. Recertification at intervals (typically 30 days initially, then less frequently) is required throughout the stay.

The 100-day spell of illness maximum

The Medicare SNF benefit is limited to 100 days per spell of illness. A spell of illness begins when a patient enters a hospital or SNF and ends when the patient has been out of both for 60 consecutive days. Subsequent admissions after a 60-day break begin a new spell with a fresh 100-day allotment.

The 100 days do not need to be continuous. A patient who spends 30 days in a SNF, goes home for two weeks, and is readmitted to a SNF for the same condition continues the same spell and the same 100-day clock. If the home stay extends to 60 consecutive days, a new spell begins.

Beneficiary cost-sharing under SNF PPS

Medicare SNF cost-sharing is tiered across the 100-day benefit period:

• Days 1-20: Medicare pays in full. No coinsurance for the beneficiary.
• Days 21-100: Beneficiary pays a daily coinsurance. For 2026, the coinsurance is $217 per day per the CMS 2026 deductible and coinsurance notice. Medicare pays the remainder of the SNF's federal per diem.
• After Day 100: Medicare coverage ends. Beneficiary is responsible for 100 percent of SNF costs.

The daily coinsurance for days 21-100 is set each year by CMS based on the Part A inpatient deductible. Over the 80 days of cost-sharing (days 21-100), the total beneficiary out-of-pocket cost at the 2026 rate exceeds $17,000.

Many beneficiaries have supplemental coverage that pays the days 21-100 coinsurance. Medicare Supplement (Medigap) plans typically cover the coinsurance. Medicare Advantage plans handle cost-sharing differently and may have their own SNF cost-sharing structure. Medicaid for dual-eligibles typically covers the days 21-100 coinsurance for QMB-eligible beneficiaries.

SNF Consolidated Billing

When a SNF resident is in a Medicare-covered Part A stay, the SNF is responsible for billing nearly all Part A services through the per diem payment. This is known as SNF consolidated billing. The consolidated billing rule means that the SNF cannot let outside vendors bill Medicare separately for services included in the bundle.

Services included in consolidated billing

• Nursing services
• Therapy services (PT, OT, SLP)
• Pharmacy services and most drugs
• Most laboratory services
• Most diagnostic radiology
• Medical supplies
• Equipment used in the SNF
• Routine therapeutic services

Services excluded from consolidated billing

A limited set of services is excluded from the SNF bundle and may be billed separately:

• Physician professional services (the physician bills Medicare Part B directly)
• Certain chemotherapy drugs
• Certain radiopharmaceuticals
• Certain dialysis services
• Certain surgical procedures
• A few high-cost diagnostic services

The excluded services list is updated annually through CMS rulemaking. SNFs and outside providers must verify which services are excluded versus bundled for each patient.

SNF Quality Reporting Program (SNF QRP)

The SNF Quality Reporting Program, authorized by the IMPACT Act of 2014, requires SNFs to report specific quality measures. SNFs that fail to report face a reduction in their annual market basket update; consult the current SNF PPS Final Rule for the operative reduction.

SNF QRP measures

The SNF QRP measures evolve through annual rulemaking. Recent measures include:

• Application of Functional Assessment / Care Plan
• Change in Self-Care Score for Medical Rehabilitation Patients
• Change in Mobility Score
• Discharge Self-Care Score
• Discharge Mobility Score
• Drug Regimen Review Conducted with Follow-Up for Identified Issues
• Percent of SNF Residents Who Improve Function
• Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
• Discharge to Community
• Medicare Spending Per Beneficiary (MSPB) for SNF
• Transfer of Health Information to Provider
• Transfer of Health Information to Patient

Public reporting

SNF QRP measures are publicly reported on Medicare Care Compare. Families can compare SNFs based on these measures, and SNFs use the data for internal quality improvement.

SNF Value-Based Purchasing (SNF VBP)

The SNF Value-Based Purchasing program, authorized by the Protecting Access to Medicare Act of 2014, applies a payment adjustment to SNFs based on performance on a hospital readmission measure.

Readmission measure

The SNF VBP measure is the SNF 30-Day All-Cause Readmission Measure (SNF-RM), risk-adjusted. The measure captures the percentage of SNF stays that result in unplanned hospital readmission within 30 days of SNF admission.

Payment adjustment

CMS withholds a portion of each SNF's Medicare Part A per diem payments and redistributes a portion of the withhold to high-performing SNFs based on the readmission measure (consult the current SNF PPS Final Rule for the operative withhold percentage). Low-performing SNFs receive less of the withhold back than they contribute. The program creates incentives to reduce avoidable readmissions through better care coordination, medication management, and discharge planning.

Expanded measure set

The SNF VBP framework has been expanded through annual rulemaking to include additional measures. Future measures may include falls, function improvement, and other outcomes.

Five-Star Quality Rating on Care Compare

The Five-Star Quality Rating System on Medicare Care Compare provides a consumer-facing comparison of SNF quality. Each SNF receives ratings on:

• Health Inspections: based on recent state survey results
• Staffing: based on RN and total nursing staff hours per resident day
• Quality Measures: based on the SNF QRP and other quality data
• Overall Rating: a composite that combines the three components

The Five-Star Rating is publicly available at medicare.gov/care-compare and is a primary tool families use to compare SNFs. Higher star ratings indicate better quality on the measured dimensions, though families should also consider factors not captured in the rating (location, specific clinical capabilities, family experience).

SNF Conditions of Participation under SNF PPS oversight

The SNF Conditions of Participation, codified at 42 CFR Part 483 Subpart B, set the operational standards that SNFs must meet to participate in Medicare. The CoPs cover:

• Resident rights and quality of life
• Admission, transfer, and discharge
• Resident assessment (MDS-based)
• Comprehensive person-centered care planning
• Quality of care
• Nursing services
• Behavioral health services
• Physician services
• Pharmacy services
• Laboratory, radiology, and other diagnostic services
• Dental services
• Food and nutrition services
• Specialized rehabilitative services
• Administration
• Quality assurance and performance improvement (QAPI)
• Infection control
• Physical environment
• Training requirements

Each requirement has associated regulatory text and survey guidance. SNFs are evaluated against the CoPs during annual recertification surveys and during complaint investigations.

OBRA 1987 Nursing Home Reform Act

The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) substantially reformed nursing home regulation. OBRA 1987's nursing home provisions were codified at Section 1819 of the Social Security Act and implemented through CMS rulemaking. The key reforms included:

• Resident rights (choice, privacy, dignity, self-determination)
• Pre-Admission Screening and Resident Review (PASRR) for mental illness and intellectual disability
• Restraint reduction (physical and chemical)
• Mandatory comprehensive resident assessment using MDS
• Staff training requirements
• Quality measurement
• Survey methodology reform

OBRA 1987 set the foundation for the modern SNF regulatory framework. Subsequent legislation and rulemaking has built on the OBRA 1987 foundation.

SNF survey and certification

SNFs participating in Medicare are subject to annual recertification surveys conducted by State Survey Agencies under contract with CMS. In Georgia, the Healthcare Facility Regulation Division within the Georgia Department of Community Health conducts SNF surveys.

Survey types

• Standard recertification survey: annual, comprehensive
• Complaint survey: triggered by specific complaints
• Revisit survey: follow-up to verify plan of correction
• Abbreviated standard survey: limited scope when warranted

F-tags

Survey findings are documented as deficiencies under F-tag numbers. Each F-tag corresponds to a specific regulatory requirement. For example, F689 addresses accidents and supervision, F695 addresses respiratory, F600 addresses freedom from abuse. The F-tag system organizes survey findings systematically.

Scope and severity

Each cited deficiency is assessed for scope (isolated, pattern, or widespread) and severity (no actual harm but potential for minimal harm, no actual harm with potential for more than minimal harm, actual harm, immediate jeopardy). The combined scope and severity drive enforcement actions.

Enforcement actions

CMS can impose enforcement actions based on survey findings:

• Plan of correction (required for all cited deficiencies)
• Directed plan of correction
• Civil money penalty (per-day or per-instance)
• Denial of payment for new admissions
• Termination from Medicare and Medicaid programs

Plan of correction

For each cited deficiency, the SNF must submit a plan of correction within a specified timeframe. The plan describes how the SNF will correct the deficiency, how it will prevent recurrence, and when the correction will be complete.

Three-day qualifying stay waivers

While the three-day qualifying hospital stay is a long-standing Medicare requirement, several waiver programs allow SNF admission without the three-day stay:

Medicare Advantage waiver

Most Medicare Advantage plans waive the three-day requirement and allow direct admission to a SNF. Beneficiaries enrolled in MA plans should check their specific plan rules.

ACO and APM waivers

Certain Medicare Shared Savings Program ACOs (particularly those in the ENHANCED track) and Bundled Payments for Care Improvement Advanced participants can admit patients directly without a three-day stay. The waiver is intended to support better care coordination and reduce unnecessary hospitalizations.

Public Health Emergency waiver

During the COVID-19 Public Health Emergency, CMS waived the three-day requirement broadly. The PHE waiver has expired.

Future expansion debate

Multiple proposals (legislative and regulatory) have called for permanent expansion of the three-day stay waiver, either universally or for specific patient populations. CBO scoring concerns about increased SNF utilization have slowed congressional action, but the issue remains on the policy agenda.

Coordination with Medicaid long-term care

For dual-eligible beneficiaries (those eligible for both Medicare and Medicaid), Medicare and Medicaid interact in important ways for SNF care.

Medicare for skilled SNF care

When a dual-eligible beneficiary qualifies for the Medicare SNF benefit (three-day stay, daily skilled services, etc.), Medicare pays the SNF under PPS. The beneficiary's days 21-100 coinsurance may be paid by Medicaid for QMB-eligible beneficiaries.

Medicaid after Medicare exhausts

After the 100-day Medicare benefit exhausts (or when the beneficiary no longer needs daily skilled services), if the beneficiary still needs nursing facility care, Medicaid long-term care coverage may apply. Medicaid LTC pays for ongoing custodial nursing facility care, subject to Medicaid eligibility requirements.

Section 1924 spousal impoverishment

For married couples where one spouse needs Medicaid LTC, Section 1924 of the Social Security Act provides spousal impoverishment protections. The community spouse can retain a Community Spouse Resource Allowance and Minimum Monthly Maintenance Needs Allowance, protecting some assets and income from the LTC Medicaid eligibility calculation. The annually-indexed maximum and minimum figures are published by CMS each calendar year.

Section 1917(b) estate recovery

After the beneficiary's death, Medicaid may recover LTC expenditures from the beneficiary's estate under Section 1917(b). The Georgia Department of Community Health administers Medicaid estate recovery in Georgia.

Georgia Medicaid LTC eligibility

Georgia Medicaid LTC has specific income, asset, and medical eligibility requirements. The application process is administered through the Georgia Department of Community Health, and the process can take several months. Families anticipating Medicaid LTC need typically begin planning well before Medicare benefits exhaust.

Worked example 1: GA SNF day 1-20 vs day 21-100 cost-sharing

Consider a Georgia Medicare beneficiary, 78 years old, hospitalized for five days after a hip fracture, then transferred to a Georgia SNF for post-surgical rehabilitation. She has Original Medicare with a Medigap Plan G policy.

SNF stay summary:

• Hospital: 5 days inpatient (qualifying)
• SNF admission within 30 days of hospital discharge
• Daily skilled services: PT, OT, skilled nursing
• Total SNF stay: 60 days

Coverage and cost-sharing:

• Days 1-20: Medicare pays in full. Beneficiary owes $0.
• Days 21-60 (40 days): Medicare pays SNF per diem minus the coinsurance. Beneficiary owes the 2026 SNF coinsurance ($217 per day) for each of those days.
• Total days 21-60 coinsurance at the 2026 rate: $217 x 40 = $8,680
• Medigap Plan G pays the coinsurance in full (Plan G covers days 21-100 SNF coinsurance)
• Net out-of-pocket to beneficiary: $0 (after Medigap)

Without Medigap, the beneficiary would owe $8,680 for the 40 days of coinsurance at the 2026 rate. With other supplemental coverage (Medicaid for dual-eligibles, retiree benefits, or other Medigap plans), the coinsurance is typically covered.

Worked example 2: PDPM five-component case-mix calculation

Consider a Georgia SNF resident admitted after coronary artery bypass graft (CABG) surgery and decompensated heart failure. PDPM classification might proceed as follows:

• Clinical category: Non-Orthopedic Surgery (for the surgical recovery) or Medical Management (depending on specific clinical course)
• Function score: derived from Section GG of the 5-day MDS
• PT case-mix group: Non-Orthopedic Surgery + moderate function = a specific PT category
• OT case-mix group: Non-Orthopedic Surgery + moderate function = a specific OT category
• SLP case-mix group: depends on swallowing/dysphagia status, mechanically altered diet status, cognitive impairment, comorbidity
• Nursing case-mix group: based on Special Care High (for IV medication management, complex cardiac care, etc.) or Special Care Low depending on specific MDS coding
• NTA score: comorbidities including diabetes, hypertension, hyperlipidemia, possible COPD, multiple medications drive the NTA score and group

The total per diem on day 1 of the stay would sum the PT, OT, SLP, Nursing, and NTA per diem rates for the assigned case-mix groups, with the NTA front-loaded adjustment applied. The resulting per diem is the federal rate multiplied by geography wage index and adjusted by the annual federal rate. Consult the current SNF PPS Final Rule for the operative federal per diem and case-mix weights.

Worked example 3: SNF three-day qualifying hospital stay scenario

Consider three different hospital scenarios and the resulting SNF coverage status:

Scenario A: Patient admitted to inpatient status on Monday at 11 PM, discharged Thursday at 2 PM. Inpatient midnights: Monday, Tuesday, Wednesday (three midnights). Three-day requirement met. SNF coverage qualified.

Scenario B: Patient admitted to observation status Monday, converted to inpatient Tuesday morning, discharged Thursday. Observation midnight: Monday. Inpatient midnights: Tuesday, Wednesday. Three-day requirement NOT met (only 2 inpatient midnights). SNF coverage denied.

Scenario C: Patient admitted to observation Monday, discharged home Wednesday, readmitted to inpatient Thursday, discharged Saturday. Observation midnights: Monday, Tuesday. Inpatient midnights: Thursday, Friday. Three-day requirement NOT met (only 2 inpatient midnights). SNF coverage denied.

These scenarios illustrate why hospital observation status is a frequent source of unexpected SNF coverage denials. Families should clarify the patient's status during the hospital stay and understand the implications for post-acute coverage.

Worked example 4: SNF 100-day spell of illness exhaustion

Consider a Georgia Medicare beneficiary, 82 years old, who has had multiple SNF stays in 2026:

• First stay: Admitted to SNF January 15 after hip fracture surgery. Daily skilled services. Discharged March 25 (70 days). Used 70 of 100 days in spell.
• Home for 20 days: March 25 through April 14. Less than 60 days, so still same spell.
• Second stay: Readmitted April 14 after hospitalization for pneumonia. Daily skilled services. Used remaining 30 days of spell, exhausted Medicare benefit May 14.
• Continued SNF need after May 14: Beneficiary still needs SNF care. Medicare does not pay. Family must consider private pay (Georgia private-pay SNF rates vary by region and facility; verify current rates with the facility and Georgia DCH), Medicaid LTC (if eligible), or alternative arrangements.

For a new spell to begin, the beneficiary must be out of the hospital and SNF for 60 consecutive days. If the beneficiary is discharged home and remains home for 60 consecutive days without any hospital or SNF stays, a new spell begins and the 100-day benefit resets.

Worked example 5: SNF consolidated billing scope

Consider a Georgia SNF resident on day 30 of a Medicare-covered Part A stay. During day 30, the resident:

• Receives physical therapy (bundled into SNF per diem)
• Receives skilled nursing care including wound care (bundled)
• Receives an antibiotic IV infusion (bundled, included in pharmacy services)
• Has lab work done at the SNF (bundled, included in laboratory)
• Is seen by her primary care physician for a check-in visit (NOT bundled, physician bills Medicare Part B for the professional service)
• Receives chest X-ray to evaluate the pneumonia (bundled, included in radiology)
• Receives a specific chemotherapy drug for breast cancer (NOT bundled if on the excluded chemotherapy list, hospital outpatient pharmacy or other provider may bill separately)

The SNF receives the PDPM per diem for the bundled services. The physician bills Medicare Part B for the professional visit (the physician's fee is paid under the Medicare Physician Fee Schedule, not the SNF PPS). The chemotherapy provider bills separately if the drug is on the excluded list.

Worked example 6: SNF coverage denial and Quality Improvement Organization review

Consider a Georgia Medicare beneficiary whose SNF coverage is terminated by the SNF after day 35, even though the beneficiary believes she still needs daily skilled care. The SNF issues a Notice of Medicare Non-Coverage (NOMNC) two days before the planned termination.

The beneficiary has a right to expedited review by the Quality Improvement Organization (QIO) for Georgia, Acentra Health (formerly KEPRO). The process:

1. The beneficiary or representative calls the Acentra Health phone number on the NOMNC
2. The QIO requests medical records from the SNF
3. The QIO has 72 hours to issue a decision
4. While the review is pending, Medicare continues to pay for the SNF stay
5. The QIO either upholds the SNF's termination (beneficiary becomes financially responsible going forward) or overturns it (SNF must continue Medicare-covered care)

If the QIO upholds the termination, the beneficiary has further appeal rights. If the QIO overturns, the SNF resumes Medicare-covered care. QIO review is a critical patient protection mechanism that prevents premature coverage termination.

Best practices for Georgia families navigating SNF care

1. Verify inpatient status during any hospital stay before the patient is discharged to a SNF. Ask the hospital case manager and review the admission paperwork. Observation status does not count toward the three-day qualifying requirement.

2. Use Medicare Care Compare to evaluate SNF options. Look at Five-Star Quality Ratings, recent survey results, staffing levels, and quality measures.

3. Tour SNFs in person when feasible. Care Compare data helps narrow the list, but a visit reveals cleanliness, staff engagement, resident interactions, and physical environment.

4. Understand the 100-day benefit clock from the start of the stay. Track days used and plan for the day 21 coinsurance and the day 100 transition to alternative coverage.

5. Confirm the resident's PDPM classification and how it affects the SNF's per diem. While PDPM is a SNF concern more than a family concern, understanding the classification helps families understand the resident's case-mix categorization.

6. Maintain regular communication with the SNF care team. Weekly care conferences, daily reports from nursing, and physician check-ins help families stay informed.

7. Request Notice of Medicare Non-Coverage (NOMNC) and use Quality Improvement Organization review when coverage is terminated prematurely. The QIO for Georgia is Acentra Health.

8. Understand the difference between Medicare SNF benefit and Medicaid long-term care. Medicare is short-term skilled care; Medicaid LTC is long-term custodial care for eligible beneficiaries. Different rules, different eligibility, different processes.

9. Begin Medicaid LTC planning early if needed. The application can take months, and asset spend-down planning often requires legal advice.

10. Use a Medicare Supplement (Medigap) plan or other supplemental coverage to address days 21-100 coinsurance. At the 2026 rate of $217 per day, the 80-day exposure adds up to more than $17,000.

11. Coordinate with the Georgia State Long-Term Care Ombudsman for advocacy support. The Ombudsman investigates complaints and supports resident rights.

12. Review the SNF's most recent survey findings. F-tag findings, scope and severity, and plan of correction history indicate quality patterns.

13. Understand resident rights under OBRA 1987. Choice of physician, privacy, dignity, freedom from restraints, participation in care decisions, and access to information.

14. Document everything: care plans, conferences, communications, and concerns. Documentation supports advocacy if disputes arise.

Common issues in Georgia SNF care navigation

1. Observation status mistaken for inpatient status, resulting in SNF coverage denial. This is the most frequent unexpected denial.

2. 30-day window for SNF admission missed due to home recovery period that extends beyond 30 days. Limited exceptions exist but require documentation.

3. Daily skilled service requirement not met because needs are primarily custodial. Medicare does not pay for custodial care alone.

4. 100-day benefit exhaustion without planning for transition to Medicaid LTC or private pay. Sudden transition can disrupt care.

5. Day 21 coinsurance not anticipated, creating financial surprise. Even with Medigap, beneficiaries without supplemental coverage owe the coinsurance.

6. MDS coding inaccuracies leading to PDPM classification disputes. SNF concern more than family concern but affects facility revenue.

7. Premature coverage termination by SNF without QIO review request. Families should know about the NOMNC and QIO review process.

8. Consolidated billing confusion when outside providers bill separately for bundled services. SNF should clarify which services are bundled.

9. Survey deficiencies not communicated to families before admission. Recent survey history is publicly available on Care Compare.

10. Inadequate care planning and family conference participation. Federal law requires family inclusion when desired by the resident.

11. Quality of life concerns not addressed. OBRA 1987 emphasizes quality of life, not just clinical quality.

12. Restraint use questions. Physical and chemical restraints are tightly regulated.

13. Discharge planning gaps. Discharge planning should begin at admission, not at the end of the stay.

14. Medicaid LTC application delays. Begin early; document carefully.

Georgia SNF landscape

Georgia has a substantial network of Medicare-certified skilled nursing facilities across the state, with a mix of urban, suburban, and rural facilities, hospital-based and freestanding facilities, and large chain operators alongside smaller independent facilities. For the current statewide count and facility roster, consult the Medicare Care Compare provider search filtered to Georgia.

Major Georgia SNF operators

• PruittHealth: Georgia-based operator with substantial presence, particularly in South Georgia. PruittHealth operates many facilities across the state and is a major employer in many Georgia communities.
• Genesis HealthCare: National operator with Georgia presence. Multiple facilities in metro and non-metro areas.
• SavaSeniorCare and successors: National operator with several Georgia facilities.
• Various independent operators: Many Georgia SNFs are independent or part of small regional chains, particularly in rural areas where they may be the only SNF in the community.

Georgia DCH oversight

The Georgia Department of Community Health, through the Healthcare Facility Regulation Division, conducts SNF surveys, investigates complaints, and enforces state and federal standards.

Georgia State Long-Term Care Ombudsman

The Georgia State Long-Term Care Ombudsman Program advocates for residents of long-term care facilities including SNFs. The Ombudsman investigates complaints, provides information about residents' rights, and supports families. The Ombudsman can be reached through the GeorgiaCares SHIP line.

Rural Georgia SNFs

Rural Georgia SNFs often serve as the only post-acute resource for their communities. Workforce challenges, particularly certified nursing assistant (CNA) recruitment, affect rural SNF operations. The Georgia State Office of Rural Health provides technical assistance.

Workforce and quality challenges

The SNF industry faces substantial workforce challenges that affect quality and operations. CNA recruitment and retention is a critical issue across Georgia, particularly in rural areas. RN staffing is required around the clock under federal regulations, and meeting that requirement is difficult in workforce-constrained markets.

The CMS Minimum Staffing Final Rule, which would have established per-resident-day total nursing-staff thresholds with specific RN and CNA minimums, was vacated by federal court in 2024. Subsequent litigation and potential regulatory action remain uncertain. Industry groups (AHCA, LeadingAge) have advocated for workforce investment alongside or instead of mandatory staffing thresholds.

Quality varies substantially across Georgia SNFs. The Five-Star Quality Rating provides a comparative snapshot, but families should also consider specific clinical needs (post-acute orthopedic rehabilitation, dementia care, ventilator weaning, etc.) when selecting a SNF.

Future SNF reform discussions

Several ongoing policy debates affect the future of the SNF framework:

Staffing mandate revival

After the 2024 court vacatur of the CMS minimum staffing rule, future regulatory or legislative action is uncertain. Workforce realities, particularly CNA shortages, create tension between mandated staffing levels and operational feasibility.

Three-day qualifying stay reform

Proposals to expand the three-day stay waiver more broadly continue. Universal waivers would simplify the system but raise CBO concerns about increased utilization.

PDPM refinements

CMS continues to refine PDPM through annual rulemaking. Coding patterns observed since PDPM implementation have prompted ongoing methodology adjustments.

Medicare Advantage SNF authorization

Medicare Advantage plan prior authorization practices for SNF care have been controversial. Plans sometimes deny or delay SNF authorization, affecting beneficiary access. Federal regulatory action on MA prior authorization continues to evolve.

Quality measure expansion

The SNF QRP and SNF VBP measure sets continue to expand. Additional measures on resident experience, function improvement, and discharge to community are under consideration.