Reading a Skilled Nursing Facility Bill, Line by Line

"Room and board — 31 days" is the least informative line on the statement and usually the largest number on it. Everything that makes a skilled nursing bill hard to read sits somewhere else: in a column of small ancillary charges underneath it, in a notice that arrives from Medicare weeks later with different dates on it, and in a five-character code on a claim form nobody sent you.

None of the three documents is wrong. They are answering different questions.

The statement, the notice and the claim are three separate papers

The facility statement is the only one addressed to you. It covers a calendar month, it comes out of the facility's business office, and it mixes two categories that have nothing to do with each other: your share of a Medicare-covered stay, and charges for things Medicare never covers.

The Medicare Summary Notice comes from Medicare, on its own schedule, and says it is not a bill near the top. Its dates are claim dates, not calendar months.

The claim is what the facility sent to its Medicare Administrative Contractor on Form CMS-1450, the UB-04. You never receive it, but its structure explains the statement. Skilled nursing Part A claims use type of bill 21X, carry occurrence span code 70 for the dates of the qualifying hospital stay, and report the payment on revenue code 0022 with a five-character HIPPS code in the rate field. The Medicare Claims Processing Manual instructs that total charges on those 0022 lines should be zero — the money is in the HIPPS code, not the charge column. Therapy appears separately on revenue codes 042x, 043x and 044x.

That last detail is worth knowing before you ask the business office anything, because the therapy lines look exactly like charges and, during a covered Part A stay, are not. Section 30.2 of the same chapter tells SNFs to report the actual charge for every line item, so a dollar figure really does sit beside them, and the units on those lines are calendar days of therapy rather than sessions or minutes — one unit for a day on which physical, occupational or speech-language therapy happened at all. They are reported so the claim is complete. The payment for them is already inside the per-diem.

The same bed at three prices, depending on the day number

A Part A stay is priced by where each day falls in the benefit period, which makes the day counter the most useful number on the statement.

CMS set the 2026 figure at $217.00 a day, up from $209.50 in 2025, in its release of 14 November 2025. The inpatient hospital deductible in that same release is $1,736 — the number that most likely appeared on the hospital bill just before this stay began.

The counter restarts only when a new benefit period does, and your parent's MSN prints the benefit period start date on the claim line. A Medigap policy may pick up the coinsurance, which is why an identical run of days shows as a charge on one family's statement and as a line paid by another insurer on the next family's.

For scale on what day 101 looks like: the CareScout Cost of Care Survey 2025 puts the national annual median for a semi-private nursing home room at $114,975, calculated across 365 days of care — roughly $315 a day — with a private room at $129,575. State medians for a semi-private room run from $67,525 in Texas to $333,975 in Alaska, with Oregon next at $201,115.

The charges that cannot be on a covered stay's bill

42 CFR 483.10(f)(11)(i) sets out categories a facility must not charge a resident for during a covered Medicare or Medicaid stay. The list is short enough to hold a statement against:

• Nursing services
• Food and nutrition services
• The activities program
• Room and bed maintenance services
• Medically-related social services
• Hospice services elected by the resident and paid under the Medicare hospice benefit or by Medicaid
• Routine personal hygiene items and services

The regulation writes that last category out in unusual detail, and the detail is the point. It names hair hygiene supplies, comb, brush, bath soap, razor, shaving cream, toothbrush, toothpaste, denture adhesive and cleaner, dental floss, moisturizing lotion, tissues, cotton balls and swabs, deodorant, incontinence care and supplies, sanitary napkins, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry. A "personal care supplies" or "briefs" line on a covered month is the first one to circle.

The charges that can be there, if somebody asked for them

Paragraph (f)(11)(ii) lists what a facility may charge to a resident's funds: telephone including a cell phone, television or radio or a personal computer, personal comfort items, cosmetic and grooming items and services beyond what Medicare or Medicaid pays for, personal clothing, personal reading matter, gifts bought on the resident's behalf, flowers and plants, the cost of social events outside the activities program, privately hired nurses or aides, a private room except where therapeutically required, and specially prepared food requested instead of what the kitchen makes.

Three conditions run with the whole of that list, in paragraph (f)(11)(iii). The item has to be specifically requested by the resident. The facility must not require a resident to request any item or service as a condition of admission or continued stay. And the facility must tell the resident, orally and in writing, that there will be a charge and what the charge will be.

Separately, 483.10(g)(18)(ii) requires written notice at least 60 days before a change to the charges for those other items and services takes effect. If a salon rate or a cable charge moved this month, a notice should predate it by two months, and asking to see it is a reasonable request.

Why a bill arrives from a hospital your parent visited for two hours

During a covered Part A stay, most of what happens to a resident is bundled into the facility's payment. 42 CFR 411.15(p)(1) excludes from Medicare payment any service furnished to an SNF resident by an outside entity unless the SNF has an arrangement with that entity — and it names physical, occupational and speech-language therapy first, "regardless of whether the resident who receives the services is in a covered Part A stay."

Paragraph (p)(2) then lists the exceptions, but only the statutory ones, and it writes them in HCPCS ranges and cross-references to the Social Security Act: physicians' services and those of a short list of other professionals, dialysis for beneficiaries with end stage renal disease, hospice, certain chemotherapy agents and their administration, radioisotopes, customized prosthetic devices, certain blood clotting factors.

The readable version lives somewhere else. Every year CMS posts a code file for its contractors, and the five-page cover note to the 2026 edition, its general explanation of the major categories, sorts everything into five categories, and four of the five are ways out of the bundle.

• Category I, services beyond the scope of an SNF. These, CMS writes, "must be provided on an outpatient basis at a hospital, including Critical Access Hospitals (CAHs), but not by a SNF" — CT scans, cardiac catheterization, MRI, radiation therapy, angiography, most outpatient surgery. Emergency services belong here too, identified on the hospital's Part A claim by revenue code 045x, and so do ambulance trips connected to any of it.
• Category II turns on who the resident is rather than what was done: dialysis for a beneficiary with end stage renal disease, hospice for a terminal illness.
• Category III, other certified providers. Chemotherapy and its administration, radioisotopes, customized prosthetics, certain blood clotting factors.
• Category IV collects the preventive and screening services, which are Part B benefits and go out on their own type of bill.
• Category V is not an exclusion at all. Its heading reads "Part B Services Included in SNF CB," and what sits under it is therapy: revenue codes 42X, 43X and 44X.

So an emergency department bill is ordinary. A therapy company's separate bill during a Part A stay is the anomaly, and the question for the business office is which of those five categories it thinks the service falls in.

The notice that says it is not a bill has one number that behaves like one

Start with how often it turns up, because second-hand descriptions of the MSN vary and a good many of them say quarterly. Medicare.gov does not. Its own page has the notice going to people with Original Medicare at least twice a year, and under "When should I get it?": "You'll get your MSN every 6 months if you get any services or medical supplies during that period. If you don't get any services or medical supplies during that period you won't get an MSN." Electronic notices run on a different clock. Choose those and you get "an email with a link to your MSN for any month you have a processed claim."

Medicare publishes an annotated walk-through of the Part A notice, and it is worth having open beside the statement, because the notice runs four pages and each one does a different job. Page 1 is a dashboard: your deductible information, and a summary of approved and denied claims under Total You May Be Billed. Page 3 carries the claims themselves, with the type of claim, the visit dates, when the current benefit period began, an approved-or-denied column, and the figure the guide describes as highlighted and in bold, Max You May Be Billed, "the total amount the facility is able to bill you." Page 4 handles denied claims and prints a date in a box: the day by which an appeal must be received — 120 days, matching 42 CFR 405.942(a), where the clock runs from receipt of the initial determination and receipt is presumed five days after the notice date.

Here is the reconciliation, using an illustrative March at 2026 rates for a resident who reached day 21 of the benefit period on the eighth of the month:

Nobody's statement is being reproduced there. The only figure in it that comes from anywhere is the $217.00, and the rest is arithmetic: 24 days of coinsurance from the eighth to the thirty-first, plus three small charges nobody's insurance covers.

The two documents should differ by exactly the non-covered items — $80.00 here. Whenever they differ by anything else, that gap is the entire question, and it is a specific enough one that a business office can answer it in a sentence.

If the reason coverage stopped is that somebody decided your parent had stopped progressing, that is a separate matter with its own paperwork, and the claim that "not improving" ends coverage is not what the Medicare manual says. Before any of it, a facility that expects Medicare to stop paying is supposed to hand you Form CMS-10055, the SNF Advance Beneficiary Notice of Non-coverage. It has a blank for the estimated cost "per day/item or service" and three option boxes. Option 1 asks for Medicare to be billed anyway, which produces an official decision on an MSN and keeps an appeal alive. Option 2 skips the billing, and its own text says you cannot appeal because Medicare will not be billed. That form is usually where the private rate first appears in writing, and it is a different document from the notice that starts a fast appeal clock.

Days your parent was not in the building, and the money after the last one

Two more places charges turn up where families do not expect them.

Bed holds. When a resident goes to the hospital or on therapeutic leave, 42 CFR 483.15(d) requires the nursing facility to give written information before the transfer covering the duration of the state bed-hold policy, the reserve bed payment policy in the state Medicaid plan, and the facility's own bed-hold policy — then, at the time of transfer, a second written notice specifying the duration. On the claim side, days away are reported with accommodation revenue code 018x, leave of absence. A bed-hold charge on the statement is measured against those two notices.

Medicaid residents. Once Medicaid is paying, most of the statement disappears and one line replaces it: applied income, also called patient liability or share of cost. Under 42 CFR 435.725, the rule for states that use SSI eligibility criteria, the state reduces its payment to the facility by the resident's income after required deductions, the first of which is a personal needs allowance — a federal floor of at least $30 a month for an aged, blind or disabled individual, with states free to protect more. Medicare premiums, deductibles and coinsurance not subject to third-party payment are deducted too. The figure on the statement should equal the figure on the state's eligibility notice, and if it does not, the state agency is the one to call.

After the last day. If a resident dies, is hospitalized, or transfers and does not return, 483.10(g)(18)(iii) requires the facility to refund any deposit or charges already paid, less its per diem rate for the days actually resided or the bed reserved, "regardless of any minimum stay or discharge notice requirements." Paragraph (iv) sets the outside limit: all refunds due within 30 days of the discharge date. Personal funds held by the facility have a parallel rule at 483.10(f)(10)(v) — conveyance of the funds and a final accounting within 30 days. Where the departure was not the family's idea to begin with, the discharge clauses themselves are the other half of that conversation.

One last thing, because it is the leverage most families do not know they hold. The written request for an itemized statement under 42 U.S.C. 1395b-7(b) is a federal right with a 30-day clock and a penalty attached to ignoring it. It comes with a second right that almost nobody uses. The 90 days start when the statement reaches you, and what goes to the Secretary has to be specific: this line was billed and that service never happened, this charge appears twice. The statute's own catch-all for the second kind is "any other billing irregularity (including duplicate billing)."

Sources

Every figure, section number and quoted phrase above was checked against the document itself on 23 August 2026, in the source rather than in a summary of it.

• 42 CFR 483.10 — (f)(10) personal funds and conveyance on discharge, (f)(11) items and services that may and may not be charged, (g)(17) Medicaid disclosure at admission, (g)(18) notice of charges, the 60-day notice of a change and the 30-day refund; 483.15(d) bed-hold notices; 411.15(p) SNF consolidated billing and its exceptions; 435.725 post-eligibility treatment of income and the personal needs allowance; 405.942 the 120-day redetermination deadline. All five sections were pulled from the eCFR versioner API at title 42's issue date of 20 August 2026.
• 42 U.S.C. 1395b-7, Explanation of Medicare Benefits — subsection (b) on the written request for an itemized statement, the 30-day period to furnish it, the civil money penalty for each knowing failure, and the 90-day window to request review by the Secretary. The statute reads "not more than $100"; CMS's own copy at 42 CFR 402.105(g) adds "as adjusted annually under 45 CFR part 102," and the row for 1395b-7(b)(2)(B) in the table at 45 CFR 102.3 currently reads $195, against $190 the year before.
• CMS, 2026 Medicare Parts A & B Premiums and Deductibles, released 14 November 2025: skilled nursing facility daily coinsurance for days 21–100 of $217.00 in 2026 against $209.50 in 2025, and an inpatient hospital deductible of $1,736.
• CMS, 2026 General Explanation of the Major Categories for Skilled Nursing Facility Consolidated Billing (PDF, five pages), together with the 2026 Part A MAC update page it sits under.
• CMS, Medicare Claims Processing Manual, Chapter 6, section 30, for type of bill 21X, occurrence span code 70, revenue code 0022 paired with a HIPPS rate code, zero total charges on 0022 lines, therapy revenue codes 042x, 043x and 044x, and revenue code 018x for leave of absence.
• Medicare.gov, "Medicare Summary Notice" (MSN), for the current mailing frequency and the electronic option, and Medicare's annotated "What's in your Medicare Summary Notice?" for Part A (PDF, product D10 — six pages of annotations over the four-page notice) for the page-by-page structure, the Max You May Be Billed figure and the printed appeal deadline.
• Form CMS-10055 (2024), the SNF Advance Beneficiary Notice of Non-coverage. The option language is quoted from the form itself.
• CareScout Cost of Care Survey 2025 and its Median Cost Data Tables (stamped 03/02/26), for a survey fielded July through November 2025. Nursing home figures in those tables are calculated on 365 days of care.

Your facility's line labels will not look like the ones in that March table. The categories they have to fall into will not change.

This page is general information, not legal, medical, or financial advice. See the terms.