Understanding Medicare’s rules for paying for nursing home care can be confusing. You might find yourself wondering, “Does Medicare pay for nursing home care, or will I have to pay out of pocket?”

Knowing what Medicare covers—and what it doesn’t—can make a big difference in how you plan for future care needs. Whether you’re considering short-term care after a hospital stay or long-term care services for an elderly loved one, this article will help you understand Medicare’s role in nursing home costs.

Let’s get started!

What Is Medicare and How Does It Relate to Nursing Home Care?

Medicare is a federal health insurance program primarily for individuals aged 65 and older, as well as younger people with certain disabilities or conditions. It’s divided into several parts, each covering different healthcare services:

• Medicare Part A: Covers inpatient hospital care, hospice care, and skilled nursing facility care.
• Medicare Part B: Focuses on outpatient care, doctor visits, and medical equipment.
• Medicare Part C (Medicare Advantage): Combines Parts A and B with additional benefits.
• Medicare Part D: Provides prescription drug coverage.

What is Nursing Home Care?

Nursing home care provides 24/7 support in facilities that help people who can no longer live on their own. These homes care for seniors and those with chronic illnesses, disabilities, or conditions that need regular supervision and help.

They combine medical care, personal support, and social activities to help residents live as comfortably and safely as possible.

Nursing home care is typically for older adults who:

• Have chronic health conditions that require ongoing medical supervision
• Need help with daily activities like bathing, dressing, and eating
• Require rehabilitation after surgery, injury, or illness
• Suffer from cognitive impairments such as dementia or Alzheimer’s disease

Nursing homes provide a wide range of services tailored to the needs of their residents. These services can be divided into two main categories: medical care and personal care and support.

Skilled Medical Care

Nursing homes employ licensed medical professionals to provide skilled care, which may include:

• Medication management
• Wound care
• Physical therapy
• Occupational therapy
• Speech therapy
• Chronic disease management

Assistance with Activities of Daily Living (ADLs)

Many nursing home residents need help with basic daily activities, including:

• Bathing and Grooming
• Dressing
• Eating
• Toileting

Social and Recreational Activities

They offer activities that provide social interaction and mental stimulation such as

• Group activities like games, crafts, and exercise classes
• Entertainment such as movie nights, music therapy, or live performances
• Celebrations for holidays and resident birthdays
• Religious or spiritual services for those who wish to participate

24/7 Supervision and Safety

To ensure residents’ safety, nursing homes provide:

• Trained staff available at all hours to address emergencies
• Secure environments for residents with memory impairments
• Assistance with mobility, including wheelchair support or fall prevention

End-of-Life and Palliative Care

For residents in their final stages of life, or battling serious illnesses, nursing homes often offer:

• Hospice care to manage pain and provide emotional support
• Palliative care to focus on comfort and quality of life
• Support for family members during a difficult time

How Medicare Covers Nursing Home Care

Medicare may cover nursing home care, but only under specific circumstances. The key factor is the type of care needed. Medicare distinguishes between:

• Skilled Nursing Facility Care: Includes medical treatments or therapy provided by skilled nursing or therapy staff.
• Custodial Care: Assistance with daily activities like bathing, dressing, or eating, which Medicare typically doesn’t cover.

When Does Medicare Part A (Original Medicare) Pay for Nursing Home Care?

Medicare’s coverage is specific and applies only in certain situations, primarily focused on short-term stays in skilled nursing facilities.

Qualifying for Skilled Nursing Facility Care

To qualify for coverage under Medicare Part A, you must meet the following requirements:

1. A Qualifying Hospital Stay

You must spend at least three (3) consecutive days as an inpatient in a hospital. Note that observation stays do not count toward this requirement, even if you stayed overnight in the hospital.

1. Skilled Care is Needed

The care you need must be medically necessary, as determined or certified by a doctor. It should involve services that require licensed professionals, such as nurses or therapists, rather than general assistance like bathing or dressing.

1. Medicare-Certified Facility

The nursing home or skilled nursing facility (SNF) must be certified by Medicare to qualify for coverage. Before admission, confirm the facility meets this requirement to avoid unexpected costs.

What Medicare Part A Covers in a Skilled Nursing Facility

When you qualify, Medicare Part A helps cover the following services in a skilled nursing facility:

• Semi-private room: Shared accommodations, unless a private room is medically necessary.
• Meals: Nutritious meals tailored to residents’ health needs.
• Physical and occupational therapy: Therapy services to help regain strength, mobility, and independence.
• Skilled nursing care: Professional nursing services, including administering medications or monitoring medical conditions.
• Medical supplies and equipment: Items like bandages, wound dressings, or mobility aids required for care.

However, Medicare coverage for skilled nursing care is limited to short-term stays, generally lasting up to 100 days per benefit period. The cost structure is as follows:

• Days 1–20: Fully covered by Medicare.
• Days 21–100: You must pay a daily co-payment.
• After 100 days: Medicare stops covering the cost entirely, and you’ll need to explore other payment options, such as Medicaid or private pay.

What Medicare Doesn’t Cover

Medicare has specific exclusions when it comes to nursing home care. These include:

• Custodial Care

Medicare doesn’t pay for assistance with daily living activities like dressing, bathing, or eating unless paired with skilled care.

• Long-Term Care

Coverage excludes services designed for ongoing, non-medical needs, even if care is provided in a certified facility.

• Room and Board

If you are living in a nursing home for non-medical reasons, such as housing or custodial care, Medicare will not cover those costs.

Medicare Part B and Nursing Home Care

Medicare Part B is part of Original Medicare and is also called “medical insurance.” Unlike Medicare Part A, which covers hospital and inpatient care, Part B focuses on outpatient services and preventive care. It covers medical services that do not require a hospital stay, including doctor visits, tests, and treatments.

To use Medicare Part B, beneficiaries pay a monthly premium, an annual deductible, and typically 20% of the Medicare-approved cost of services after the deductible is met.

What Does Medicare Part B Cover?

Although Part B does not cover room, board, or custodial care in a nursing home, it can cover medical and therapy services that a resident might require while living there. Here’s a breakdown of what it includes:

• Doctor Visits

Residents in nursing homes often need regular check-ups or consultations with doctors to monitor chronic conditions or treat new health issues. Medicare Part B covers these doctor visits, ensuring residents can access necessary medical care.

• Durable Medical Equipment (DME)

If a nursing home resident needs medical equipment like wheelchairs, walkers, oxygen tanks, or hospital beds, Medicare Part B helps pay for renting or purchasing these items. The equipment must be prescribed by a doctor and deemed medically necessary.

• Outpatient Therapies

Physical therapy: Medicare Part B covers therapy to help residents regain mobility and strength after an illness or surgery.

Occupational therapy: This focuses on helping residents relearn daily activities and improve their quality of life.

Elderly man undergoing physical therapy – medicare nursing care]

Speech-language therapy: If a resident has difficulty speaking or swallowing due to a medical condition, Part B may cover therapy to address these issues.

• Preventive Services

Preventive care, such as flu shots, cardiovascular screenings, and diabetes management, is covered under Part B. These services help nursing home residents maintain their health and avoid more serious complications.

Example: How Medicare Part B Supports Nursing Home Residents

Imagine a nursing home resident named Mrs. Harris. She recently had hip surgery and now lives in a skilled nursing facility. Although Part A covered her initial hospital stay and a portion of her short-term skilled nursing care, Part B comes into play for her follow-up needs:

• Doctor Visits: Mrs. Harris sees a specialist every two weeks to monitor her recovery. Part B covers the cost of these visits.
• Durable Medical Equipment: Her doctor prescribes a walker to aid her mobility. Part B helps cover the cost of the walker.
• Therapies: To regain her strength and mobility, she undergoes physical therapy sessions in the facility. Medicare Part B pays for these outpatient therapy services.

Medicare Part C (Medicare Advantage) and Nursing Home Care

Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare that offers additional benefits and coverage options.

These plans are managed by private insurance companies approved by Medicare. They bundle the services of Part A (hospital insurance) and Part B (medical insurance). Some plans also include Part D for prescription drug coverage, making them an attractive all-in-one solution for many beneficiaries.

Medicare Advantage plans offer all the coverage of Original Medicare, but they often go a step further. Many plans provide extra benefits not covered by Original Medicare, such as:

• Vision and Dental Coverage: Includes services like eye exams, glasses, dental cleanings, and restorative dental work.
• Hearing Coverage: Some plans provide coverage for hearing exams and hearing aids.
• Wellness Benefits: Programs for gym memberships, nutrition counseling, and even transportation to medical appointments.
• Personal Care Services: Assistance with daily activities, such as bathing or meal preparation, in certain plans.

Because these plans are administered by private insurance companies, benefits and costs can vary widely. Consult with your medicare advantage administrator before making decisions about skilled nursing care.

How Much Does Medicare Pay for Nursing Home Care?

When it comes to the cost of nursing home care, many families find themselves asking: How much will Medicare cover, and how much will I have to pay out of pocket? Here’s what you should expect.

Cost Breakdown for Medicare Part A

Medicare Part A provides coverage for skilled nursing care following a qualifying hospital stay. However, the level of coverage varies depending on how long you remain in a nursing home and the type of care you need.

• Short-Term Care (1–20 days):
  Medicare Part A covers the full cost of care for up to 20 days. This means that if your loved one is in a skilled nursing facility for this period and has met the necessary qualifications, they won’t have to pay anything for the stay. The services covered include skilled nursing care, meals, and other medical supplies required during the stay.
• Days 21–100:
  Medicare continues to cover skilled nursing care for up to 100 days, but there is a co-payment for each day starting on day 21. In 2024, the co-payment is approximately $204 per day. This co-payment can add up quickly, making it essential to plan for these additional costs. Be aware that the co-payment only applies to skilled care, not custodial care, which Medicare doesn’t cover.
• Beyond 100 Days:
  After 100 days in a skilled nursing facility, Medicare stops paying entirely. Any further care needed will be fully out of pocket for the patient or their family. For long-term stays beyond 100 days, you will have to explore other options.

The Role of Medigap Plans

Since Medicare doesn’t cover all the costs of nursing home care, many people choose to buy Medicare Supplement Plans (Medigap) to help cover the gaps. Medigap plans help pay for things that Original Medicare doesn’t fully cover, such as co-payments, coinsurance, and deductibles.

For example:

• If your loved one needs skilled nursing care for 30 days (days 21-30), Medicare Part A would cover a portion of the cost, but the co-payment would be $204 per day.
• If you have a Medigap plan, it may cover these co-payments, leaving you with little or no out-of-pocket expenses for that period.

Medigap plans vary, so it’s important to carefully consider the type of coverage your loved one may need. Some plans may cover most of the daily co-payments for nursing home stays, while others might only cover part of the cost.

Medigap plans also don’t cover custodial care; the type of care typically required for long-term stays in nursing homes. This type of care involves assistance with daily activities such as bathing, dressing, and eating and is generally not covered by Medicare or Medigap.

What Happens If Medicare Doesn’t Cover Care?

While Medicare provides vital coverage for short-term stays in skilled nursing facilities, it doesn’t cover long-term or custodial care beyond a certain period. So, what happens if your loved one’s nursing home care extends beyond Medicare’s coverage limits? Fortunately, there are alternative ways to manage the financial burden of long-term care.

Medicaid

If Medicare stops covering nursing home care after 100 days, Medicaid may step in as an alternative. Unlike Medicare, Medicaid is designed to help low-income individuals cover long-term care costs, including care in a skilled nursing facility, for those who qualify.

To qualify for Medicaid, you’ll need to meet both medical and financial eligibility requirements.

• For the medical side, your loved one must typically need a level of care that is equivalent to what is provided in a nursing home, which includes skilled nursing or custodial care.
• On the financial side, Medicaid has strict income and asset limits, which vary by state.

For example, your loved one’s income must fall below a certain threshold, and they may not have more than a set amount of savings or assets. However, some assets may be exempt, such as a primary home, personal belongings, and a car, but these rules can differ based on the state.

If you meet these eligibility requirements, Medicaid can cover most or all of your loved one’s nursing home care costs. This includes room and board, personal care services, and skilled medical care.

However, it’s important to note that Medicaid’s coverage may vary by state and nursing home, and not all facilities accept Medicaid. Applying for Medicaid can be complex and time-consuming, so it’s important to start early and ensure all necessary paperwork is completed.

Long-Term Care Insurance

Another option to consider if Medicare doesn’t cover nursing home care is long-term care insurance specifically designed to help cover the costs of long-term care services, including stays in nursing homes, assisted living facilities, and even home health care.

The cost of premiums depends on factors like the individual’s age, health, and the level of coverage desired. Some policies cover skilled nursing care and custodial care, which can be important if your loved one requires help with daily activities like dressing, bathing, or eating.

Purchasing long-term care insurance while your loved one is younger and healthier can help lower premiums, and the earlier you buy it, the more comprehensive the coverage might be.

Coverage for long-term care policies differ, be sure to ask for the extent of coverage.

Paying Out of Pocket

Paying out of pcoket is the next option If neither Medicare nor Medicaid applies. Nursing home care can be costly, and the costs can quickly add up over time.

A private room in a nursing home can cost over $100,000 per year, depending on the location and facility. If you don’t have sufficient insurance coverage, you may need to tap into personal savings or find other ways to pay for care.

Here are a few strategies for paying out of pocket for nursing home care:

• Personal Savings: If your loved one has substantial savings, this might be a good option for covering care costs. However, it’s important to consider the long-term sustainability of using these funds, especially if the care is needed for an extended period.
• Reverse Mortgages: A reverse mortgage allows homeowners to borrow against the value of their home, with no monthly payments required. The loan is repaid when the house is sold or the borrower dies.
• Life Insurance Loans or Accelerated Benefits: Some life insurance policies have provisions that allow policyholders to take loans or advance a portion of their death benefit if they need funds for long-term care. While these options can help, they will reduce the death benefit left to beneficiaries.
• Veterans Benefits: If your loved one is a veteran, they may be eligible for additional benefits that help pay for nursing home care. The Veterans Administration (VA) provides funding for long-term care for eligible veterans, including care in VA facilities and private nursing homes. Check with the VA for more details on eligibility and coverage.

Tips for Navigating Medicare Coverage for Nursing Home Care

Navigating Medicare coverage for nursing home care can be challenging, especially if you’re trying to balance financial concerns with ensuring your loved one receives the care they need. The following tips can help simplify the process and ensure you make informed decisions.

Research Nursing Homes Certified by Medicare

Finding a nursing home certified by Medicare can ensure your loved one’s stay is eligible for coverage. Medicare-certified facilities meet specific health and safety standards, which gives you peace of mind about the quality of care.

Here’s how you can identify Medicare-certified nursing homes:

• Use Medicare’s Nursing Home Compare Tool: Visit the official Medicare website and use their Nursing Home Compare tool. This tool allows you to search for Medicare-certified facilities in your area and compare their ratings based on quality of care, staffing levels, and health inspections.
• Ask for Recommendations: Reach out to doctors, social workers, or discharge planners at the hospital. They often have a list of nursing homes that accept Medicare and can provide recommendations based on your loved one’s needs.
• Visit Facilities in Person: Schedule visits to potential nursing homes to assess the environment, cleanliness, and staff interactions with residents. Confirm their Medicare certification during your visit and ask specific questions about services covered under Medicare.

Work with a Medicare Advisor

Understanding Medicare’s complex rules and coverage options can feel overwhelming, especially when dealing with the emotional stress of transitioning your loved one into a nursing home. That’s where working with a Medicare advisor can be incredibly helpful.

A Medicare advisor can offer

• Personalized Guidance: Advisors can help you understand which Medicare plans best fit your loved one’s health and financial needs, including exploring Medicare Advantage plans that may offer additional benefits.
• Clarifying Coverage: An advisor can explain what Medicare will and won’t cover, including specific costs for skilled nursing care, co-pays, and coverage limitations.
• Assistance with Paperwork: Navigating Medicare paperwork and filing claims can be time-consuming and confusing. An advisor can help ensure all forms are completed correctly to avoid delays in coverage.
• Exploring Supplemental Options: They can guide you in choosing Medigap or long-term care insurance to fill coverage gaps and reduce out-of-pocket expenses.

You can find Medicare advisors through organizations like your local State Health Insurance Assistance Program (SHIP) or private Medicare consultants. While some services are free, others may charge a fee, so it’s essential to explore your options.

Preparing for a Smooth Transition

Preparation can help ease the transition and reduce stress for your family and your beloved senior. Here are some practical steps to take:

Gather Necessary Documents:
To ensure the transition goes smoothly, have the following documents ready:

• Medicare Card: This will be needed to confirm eligibility and billing.
• Health Insurance Information: Include details about Medigap or Medicare Advantage plans if applicable.
• Medical Records: Provide the nursing home with up-to-date medical histories, medication lists, and doctor’s orders for care.
• Financial Information: If applying for Medicaid alongside Medicare, gather income statements, tax records, and details of assets.

Plan for Financial Needs:

• If Medicare won’t cover long-term care, research other payment options like Medicaid or long-term care insurance. Start this process early, as financial eligibility requirements can be strict and take time to meet.

Coordinate with the Facility:

• Speak with the nursing home’s admissions staff to understand what additional paperwork or steps they require.
• Confirm what services are covered under Medicare, including skilled nursing care, therapy, and medical equipment.

Pack Thoughtfully:
Help your loved one feel at home by packing personal items like photos, favorite blankets, and books. Include clothing and toiletries, but confirm with the nursing home what items they provide.

Communicate Openly:
Involve your loved one as much as possible to ensure they feel heard and respected. Share details about the facility, the care they’ll receive, and what their daily routine might look like.

Monitor the Transition:
Once your loved one has moved into the nursing home, check in frequently to ensure they are adjusting well. Speak with staff regularly to stay informed about their care plan and any changes to their health.

Takeaway

Exploring Medicare’s coverage for nursing home care can feel overwhelming, but knowing the basics helps. Medicare Part A covers short-term skilled nursing facility stays if your loved one meets specific requirements, such as a qualifying hospital stay and a need for skilled care. Coverage includes the first 20 days in full, with co-pays from days 21 to 100, but it doesn’t cover long-term custodial care or personal services.

If Medicare doesn’t apply, options like Medicaid, long-term care insurance, or personal savings may need to be explored. Proactive Planning—researching certified facilities, consulting Medicare advisors, and organizing finances—can make this process smoother.

Sometimes, even after a short-term nursing home stay, your loved one may still need help at home. That’s where Amy’s Eden Senior Care steps in. Our experienced caregivers provide personal and home health care services to ease recovery at home.

For long-term care outside of the home, our assisted homes offer an ideal solution. With just two residents per home and 24/7 staff, your loved one will thrive with personalized care in their golden years.

Contact us today to learn how we can support you and your loved one.