Medicare and nursing home coverage

If a person has Medicare and requires skilled nursing care, Medicare only helps cover the stay in a Certified Nursing Facility. And the medical provider must deem it medically necessary. Medicare will not cover a stay for patients who just need custodial care.

Does Medicare cover nursing homes?

Medicare covers nursing home care only in instances where a provider determines an individual requires daily, skilled nursing care for treating a hospital-related medical condition. 

To be eligible for Medicare nursing home coverage, the member must first have a qualifying hospital stay. Medicare Part A helps cover the nursing home care. It also helps cover hospitalization, skilled nursing care, lab tests, surgery, and home health care.

Medicare coverage for nursing home care is limited to 100 days. And the member must receive skilled care for recovery after an inpatient hospitalization.

Medicare nursing home coverage eligibility

For Medicare to cover nursing home costs, a member must meet the following criteria.

• Provider determines the condition requires skilled nursing care.
• Must first had a qualifying hospital stay of at least 3-day-consecutive inpatient hospitalization.
• Must receive care at a Medicare-approved skilled nursing facility. 

What nursing home services does Medicare covered?

If the member meets the eligibility criteria described above, Medicare helps cover the below services.

• Semi-private room
• Medical supplies and equipment
• Medications
• Occupational therapy
• Physical therapy
• Skilled nursing care
• Speech or language therapy
• Ambulance transportation to health care providers
• Meals
• Medical social services

When does Medicare not cover nursing home care?

Medicare does not cover custodial care if it’s the only care a patient needs. Most nursing home care is custodial care which helps with activities of daily living (like bathing, eating, dressing, and using the bathroom). Or personal needs that can be done safely and reasonably without professional skills or training.

Medicare Plan A benefits do not cover nursing home care beyond 100 days. Even when the patient is receiving skilled nursing care. This means that after 100 days of coverage all costs revert back to the patient. 

Which Medicare plans cover nursing homes?

• Medicare Part A: If the member has Original Medicare, Part A benefits help cover nursing home care. But the patient must meet the eligibility criteria.
• Medicare Advantage: An individual can get coverage for nursing home care with a Medicare Part C or Medicare Advantage plan. Medicare Advantage Special Needs Plans  (SNPs) offer coverage for custodial care for patients with qualifying chronic conditions.
• Medicare Part D: Medicare Part D offers prescription drug coverage and covers the cost of prescription drugs while a patient is living in a nursing home.
• Medigap: Medigap does not cover long-term care, but can help cover the copayments incurred when Medicare Part A helps cover skilled nursing care at a nursing home. 

How long and how much does Medicare pay for nursing home?

• Days 1 to 20: Medicare pays for the full cost of the nursing home care.
• Days 21 to 100: For days 21 through 100, Medicare helps cover the cost of skilled nursing care. But the member must pay the daily coinsurance which is $204 per day in 2024.
  
• Days 101+: Medicare does not cover skilled nursing care at a nursing home beyond 100 days. Once the benefit period ends, the patient pays all costs.

Does Medicare pay for nursing homes for Alzheimer’s patients?

Medicare does not pay for long-term custodial care at a nursing home for patients with Alzheimer’s. If a provider determines an individual need skilled nursing care, Medicare helps cover costs for the nursing home care for up to 100 days like in all other cases.

Medicare does cover some health care services for patients with Alzheimer’s.

• Medicare Part A helps cover inpatient hospital care and some doctors’ fees.
• Medicare Part D covers most prescription drugs for Alzheimer’s patients. 
• Medicare Part A helps cover up to 100 days of skilled nursing home care.

Nursing homes that accept Medicare

Medicare only cover costs if the member goes to a Medicare-approved facility. 

If a member is in hospital care, their provider or social worker finds a nursing home that meets their patient’s medical needs and is certified by Medicare. The caregiver or hospital staff arranges the patient’s transfer to the nursing home.

Medicare also has helpful resources  to help with finding nursing homes that accept Medicare in the member’s area. 

Options that help pay for nursing home care

Medicaid

Medicaid is a federal program available to people with low incomes. Medicaid can help cover nursing home costs for those who meet the eligibility criteria. Medicaid covers 100% of nursing home costs in most cases when eligibility requirements are met. And includes skilled nursing care, rehabilitation, and long-term care at a nursing home. 

Private Insurance

Individuals can purchase long-term care insurance from private insurance companies to help cover part or all of the costs of nursing home care. However, these types of plans tend to increase with age. So, it’s best to purchase them early.

Veterans Administration

If a person needs coverage for long-term nursing home care and served in the military, they may qualify for aid through the U.S. Department of Veterans Affairs.