Medicare Skilled Nursing Facility Coverage: The 3-Day Rule, 100 Days and What You Pay in 2026

Three days, admitted as an inpatient, not counting the day you go home. That is the door into Medicare's skilled nursing facility benefit, and it's easy to find out it was never opened only after the bill arrives. Get through it and Original Medicare Part A covers up to 100 days of skilled care in each benefit period: the first 20 with no daily charge, then $217 a day in 2026 for days 21 through 100, then nothing at all.

Below is how the rule actually works: what counts as a qualifying stay, why "observation" nights don't, what the 2026 numbers mean in dollars, what happens when the facility says Medicare coverage is ending, and where long-term care fits in Washington, because Medicare doesn't pay for it.

Source: 42 CFR 409.30 and 409.61; CMS 2026 Part A and B fact sheet; Medicare.gov, Skilled nursing facility care.

The five conditions for coverage

The federal rule is in 42 CFR 409.30 and 409.31. Medicare.gov lists six conditions; I've folded two of them (Medicare-certified facility, condition linked to the stay) into one below. You have to meet every one:

1. You have Part A and days left in your benefit period.
2. You had a qualifying inpatient hospital stay. That means a medically necessary inpatient stay of at least 3 consecutive days. The regulation counts calendar days, starting with the day you're admitted as an inpatient and not counting the day you're discharged.
3. You enter the SNF within 30 days of leaving the hospital. There's an exception when skilled care wouldn't be medically appropriate within 30 days; then you can be admitted when an active course of treatment can start.
4. A doctor says you need daily skilled care. Daily means skilled nursing 7 days a week, or skilled rehab at least 5 days a week when therapy isn't offered 7 days (42 CFR 409.34). Skilled means care that needs nurses or therapists to do it or supervise it safely: IV medications, wound care, physical, occupational or speech therapy.
5. The care is in a Medicare-certified SNF, for a condition linked to the hospital stay. It has to be something that was treated during the qualifying stay (even if it wasn't why you were admitted), or a new condition that started while you were in the SNF for that one.

What Part A pays for once you're in: a semi-private room, meals, skilled nursing, therapy, medical social services, medications, supplies and equipment used in the facility, dietary counseling, and ambulance trips when other transport would endanger your health, per Medicare.gov. The SNF can be a separate facility, a unit inside a nursing home, or a "swing bed" in a hospital. Medicare.gov notes that if the hospital you're in has its own SNF and a bed is available, you may choose to stay there.

The main exception Medicare.gov lists for Original Medicare: if your doctor is part of an Accountable Care Organization approved for a "Skilled Nursing Facility 3-Day Rule Waiver," you may not need the full stay. It isn't automatic. Ask the doctor or the hospital's case manager before you assume it applies.

Observation status: the trap

Here's what catches people. You can spend three or four nights in a hospital bed, in a gown, with an IV, and still be an outpatient. Medicare's handbook is plain about it: you're an inpatient only when the hospital formally admits you with a doctor's order. Emergency room time and "observation services" are outpatient care, "even if you spend the night in the hospital." None of those days count toward the three.

Look at how the count works in practice. This is a hypothetical stay where the patient arrives Monday evening.

Source: 42 CFR 409.30(a)(1); Medicare & You 2027, p. 30; Medicare.gov, Skilled nursing facility care. Hypothetical example by Maru Insurance.

That stay qualifies, barely. Move the admission order to Thursday and it doesn't: same six days in the building, two inpatient days, and Part A pays nothing toward the SNF that follows.

The MOON. If you're kept under observation for more than 24 hours, the hospital has to give you a Medicare Outpatient Observation Notice (form CMS-10611), which says you're an outpatient and how that affects what you pay. CMS requires it for Medicare Advantage enrollees too. If someone hands you a MOON, that's your signal: those days don't count.

If you were admitted and then switched to observation. This is newer. After a federal court case, Alexander v. Azar, CMS wrote a final rule effective October 11, 2024 creating appeal rights for people who are formally admitted and then reclassified as outpatients getting observation services. Since February 14, 2025, the hospital is supposed to give you a Medicare Change of Status Notice (CMS-10868) before you leave. It explains that the stay will be billed under Part B instead of Part A and that Medicare won't cover a SNF stay afterward. You can ask the BFCC-QIO (more on them below) for a fast appeal, ideally while you're still in the hospital, and Medicare.gov says a decision comes about 2 days after you file. If you win, you owe the Part A inpatient deductible and may qualify for a covered SNF stay within 30 days of discharge.

The look-back version of this right, for status changes between January 1, 2009 and February 13, 2025, had a 365-day filing window that closed January 2, 2026. Late requests are denied unless you can show good cause, so if your family paid for a SNF stay in that situation, talk to SHIBA before you give up on it.

What I'd do: every day in the hospital, ask "Is my parent an inpatient or under observation?" The handbook literally tells you to ask that each day. If the answer is observation and a SNF is likely, ask the doctor whether the medical record supports admission. You can't force an admission, but you can ask the question while it still matters.

What a SNF stay costs in 2026

The daily coinsurance isn't picked from the air. By regulation it's one-eighth of the Part A inpatient hospital deductible (42 CFR 409.85). The 2026 deductible is $1,736, so the SNF coinsurance is $217 a day.

Source: CMS 2026 Part A and B fact sheet; Medicare.gov, Skilled nursing facility care; 42 CFR 409.61(b).

20 days$030 days$2,17040 days$4,34060 days$8,680100 days$17,360

Source: CMS 2026 fact sheet; 42 CFR 409.61(b). Computed by Maru Insurance; excludes the hospital deductible.

Show the numbers

Item	You pay
20 days	$0
30 days	$2,170
40 days	$4,340
60 days	$8,680
100 days	$17,360

Two details that change the math. First, the coinsurance follows the calendar year in which you get the care, not the year the stay began. A stay that runs from December into January switches to the 2027 rate on January 1. CMS hasn't announced the 2027 Part A deductible or SNF coinsurance yet; as of October 25 there's no 2027 fact sheet. The 2026 figures came out on November 14, 2025; the 2027 amounts will likely be announced in the same season, but until CMS publishes them, plan with the 2026 figures.

Second, the 100 days are a maximum, not a promise. Coverage lasts only as long as you need and get daily skilled care. Many stays end well before day 100, once daily skilled care is no longer needed.

Benefit periods and the 100 days

The 100 days aren't per year and they aren't per lifetime. They're per benefit period. Under 42 CFR 409.60, a benefit period starts the day you're admitted to a hospital or SNF and ends once you've gone 60 days in a row without being an inpatient in either one (for the SNF, at a skilled level of care). When a new benefit period starts, the 100 SNF days reset, and so does the hospital deductible.

Source: 42 CFR 409.60 and 409.61(c); Medicare & You 2027, p. 31.

The last row is the one families don't expect. Someone who stays in a nursing home long term, but only needs custodial help, isn't an inpatient at the skilled level. So the 60-day clock can run out while they're still living in the facility, and a later hospital stay can start a fresh benefit period. Whether a particular stretch counted as skilled is a facts question; if it matters for your family, ask the facility's business office how they've been billing it.

"Not improving" is not a reason to stop

Some providers and reviewers have believed Medicare covers skilled nursing and therapy only when a patient is expected to improve. CMS says that belief is wrong. A 2013 court settlement, Jimmo v. Sebelius, made CMS restate it in its manuals: Medicare covers skilled nursing and skilled therapy in a SNF when you need skilled care to maintain your function or to prevent or slow decline, as long as the other coverage rules are met. Coverage turns on whether you need skilled care, not on whether you're getting better.

The regulation already said so. 42 CFR 409.32(c): "The restoration potential of a patient is not the deciding factor." The Medicare & You handbook gives the exact example: if you're discharged only because you aren't improving, but still need skilled care to keep your condition from getting worse, you can appeal.

The settlement doesn't stretch the benefit past 100 days and doesn't turn custodial care into skilled care. What it does is take away one bad reason for cutting someone off. If you hear "she's plateaued" as the explanation, ask what skilled service she no longer needs, and get it in writing.

When the facility says coverage is ending

A SNF can't just stop billing Medicare and start billing you. Under 42 CFR 405.1200 it has to give you a written Notice of Medicare Non-Coverage (NOMNC) no later than 2 days before covered services end. The notice shows the date coverage ends and how to ask for a fast appeal. If you don't get one, ask for it.

The fast appeal goes to the Beneficiary and Family Centered Care Quality Improvement Organization, or BFCC-QIO, an independent reviewer under contract with Medicare. For Washington that's Acentra Health, which handles Region 10 (Washington, Oregon, Idaho and Alaska). Beneficiary helpline: 1-888-305-6759 (TTY 711). The number should also be printed on your notice.

Source: Medicare.gov, Fast appeals; 42 CFR 405.1200(b) and 405.1202(b); Acentra Health BFCC-QIO, Washington.

The regulation phrases the deadline as noon of the day after you receive the notice; Medicare.gov phrases it as noon of the day before the end date. With a 2-day notice those land on the same day. Go by the deadline printed on your notice and don't wait for the last hour. When you call, say why you think skilled care is still needed: the therapy is preventing decline, the wound still needs a nurse, the discharge plan isn't safe. You don't have to prove it yourself; the QIO pulls the records.

If you're in a Medicare Advantage plan, the SNF still has to give you the notice and you have the same kind of fast appeal to an independent reviewer, under 42 CFR 422.624 and 422.626. If you miss that deadline in a plan, Medicare.gov says you can ask the plan for a fast reconsideration instead, but services will only be covered if the decision goes your way.

Medigap and Medicare Advantage

Medigap. Medicare Supplement plans are standardized by letter, so the SNF coinsurance benefit is the same for a given letter no matter who sells it. From the CMS Medigap guide: Plans A and B don't cover SNF coinsurance. Plans C, D, F, G, M and N cover it in full. Plan K covers 50% and Plan L covers 75%, and those two have yearly out-of-pocket limits ($8,000 and $4,000 in 2026, per Medicare.gov). Medigap pays the coinsurance for days 21 through 100 only. It doesn't add days past 100 and doesn't pay for long-term custodial care.

Source: CMS, Choosing a Medigap Policy (2026); Medicare.gov, Compare Medigap plan benefits. Hypothetical computed by Maru Insurance; plans C and F are only available to people eligible for Medicare before January 1, 2020.

More on how the letters differ and Washington's Medigap rules is in my post on Medigap in Washington, and on our Medicare Supplement insurance in Washington page.

Medicare Advantage. A plan has to cover everything Original Medicare covers, SNF care included, but the rules for getting it can differ. Medicare.gov says plans may waive the 3-day hospital stay requirement, and that you may be charged copayments during the first 20 days. The handbook says you may need approval (prior authorization) from the plan before it covers certain services. So the questions for a plan are practical ones: Does it require the 3-day stay? Is prior authorization needed for a SNF? Which facilities are in network? What are the daily copays? The plan's Evidence of Coverage is where to look. For how the two paths compare overall, see Medicare Advantage vs. Medigap in Washington.

After day 100: long-term care in Washington

The SNF benefit is for recovery or skilled maintenance. Help with bathing, dressing, eating and getting to the bathroom, when that's all someone needs, is custodial care, and Medicare doesn't pay for it, in a nursing home or at home. Neither does Medigap.

In Washington there are two public options worth knowing:

• WA Cares Fund. Benefits became available July 1, 2026. The 2026 lifetime benefit is $36,500, it grows with inflation, and it pays approved providers for things like in-home care, adult day services and home modifications. To use it you need to have paid in long enough and need help with at least 3 of 7 daily activities for 90 days or more (WA Cares, Qualify). Many people already retired before contributions began in 2023 won't have earned it. Details in my post on WA Cares Fund.
• Apple Health (Medicaid). You can have Medicare and still qualify for Apple Health, which can include long-term services and supports if you meet the income and resource limits (HCA). Medicaid covers things Medicare normally doesn't, like nursing home care and personal care services, per Medicare.gov. You apply for long-term services through Washington Connection. How the two programs fit together is in Apple Health and Medicare.

Choosing a facility: Medicare's Care Compare tool lets you find and compare Medicare-certified nursing homes near you. Use it alongside a visit and your own questions. And for help with any of this at no cost, SHIBA, run by the Office of the Insurance Commissioner, has volunteers who give free, unbiased help with Medicare: 800-562-6900, 8:30 a.m. to 4:30 p.m., Monday through Friday, or start at the OIC's SHIBA page. The bigger picture of Parts A through D is on our Medicare in Washington page.

Questions

What is the 3-day rule for Medicare skilled nursing coverage?

Original Medicare covers SNF care only after a medically necessary inpatient hospital stay of at least 3 consecutive days, counting the day you're admitted as an inpatient but not the day you're discharged. Time in the emergency room or under observation doesn't count, even overnight.

How much does Medicare pay for a skilled nursing facility in 2026?

Per benefit period, Part A pays in full for days 1 to 20. For days 21 to 100 you pay $217 a day in 2026. After day 100 you pay all costs.

Do observation days count toward the 3-day hospital stay?

No. Observation is outpatient care. If you're under observation more than 24 hours, the hospital must give you a Medicare Outpatient Observation Notice (MOON). If you were admitted and then changed to observation, you may have a right to a fast appeal through the BFCC-QIO.

Can Medicare stop paying because I'm not improving?

Not for that reason alone. Under the Jimmo settlement, Medicare covers skilled nursing and therapy needed to maintain your condition or slow decline, as long as other coverage rules are met. If you're discharged only because you aren't improving, you can appeal.

Does Medicare pay for long-term nursing home care?

No. Medicare and Medigap don't pay for custodial long-term care. In Washington, WA Cares Fund and Apple Health long-term services and supports are the main public options for people who qualify.

Federal Medicare rules, your plan's own documents and the facts of your stay control what's covered. Confirm your situation with 1-800-MEDICARE, SHIBA, the BFCC-QIO or a licensed agent, and talk to an attorney for legal questions.

Sources

1. Medicare.gov: Skilled nursing facility care
2. CMS: 2026 Medicare Parts A and B premiums and deductibles fact sheet (Nov 14, 2025)
3. eCFR: 42 CFR 409.30, basic requirements for posthospital SNF care
4. eCFR: 42 CFR 409.31, level of care requirement
5. eCFR: 42 CFR 409.32, criteria for skilled services
6. eCFR: 42 CFR 409.34, criteria for daily basis
7. eCFR: 42 CFR 409.60, benefit periods
8. eCFR: 42 CFR 409.61, general limitations on amount of benefits
9. eCFR: 42 CFR 409.85, SNF care coinsurance
10. eCFR: 42 CFR 405.1200, notifying beneficiaries of provider service terminations
11. eCFR: 42 CFR 405.1202, expedited determination procedures
12. eCFR: 42 CFR 422.624, notifying MA enrollees of termination of provider services
13. eCFR: 42 CFR 422.626, fast-track appeals of service terminations (MA)
14. CMS: Medicare & You 2027 handbook
15. CMS: Medicare Outpatient Observation Notice (MOON)
16. Federal Register: Appeal Rights for Certain Changes in Patient Status, final rule (Oct 15, 2024)
17. Medicare.gov: Appeal when a hospital changes your status to outpatient getting observation services
18. Medicare.gov: Appealing a change in status during a hospital stay (retrospective appeals)
19. Medicare.gov: Fast appeals
20. Acentra Health BFCC-QIO: Washington
21. CMS: Jimmo Settlement
22. Medicare.gov: Long-term care
23. CMS: Choosing a Medigap Policy (2026)
24. Medicare.gov: Compare Medigap plan benefits
25. WA Cares Fund: Benefits
26. WA Cares Fund: Qualify
27. Washington Health Care Authority: Age 65 and older or Medicare eligible
28. Medicare.gov: Medicaid
29. Washington OIC: SHIBA Medicare help
30. Medicare.gov: Care Compare