Does Medicare pay for nursing home care?
- WCFIS
- Mar 31
- 5 min read
Does Medicare pay for nursing home care?
By Zia Sherrell
Updated July 24, 2024 at 6:48 AM
Medicare does not usually cover long-term nursing home costs. However, some plans may fund temporary stays in a skilled nursing facility (SNF) if someone needs specialized care.
Medicare classifies nursing home care as either skilled or custodial.
Medicare has four parts that cover various healthcare services, including hospital treatment, outpatient care, and prescription drugs. Understanding what each plan includes can make it easier to seek and receive healthcare.
This article looks at how Medicare can help with some nursing home costs, what help is available for hospice care insurance, and how to find a nursing home.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
When does Medicare cover nursing home care?
Morsa Images/Getty ImagesThis article originally appeared on Medical News Today
According to the Centers for Disease Control and Prevention (CDC), around 1.3 million adults in the United States lived in a nursing home in 2020.
As a general rule, Medicare Part A covers a person for 100 days of acute care in an SNF for each benefit period. Every day, the individual must receive the skilled care that they need for their recovery.
A person with professional medical training, such as a registered nurse or physical therapist, delivers this level of care. Doctors generally expect that people in an SNF will recover from their illness or injury.
Medicare does not cover custodial care for people who need ongoing help with essential activities, such as eating, bathing, or dressing. Custodial or nonmedical care usually means a continuous, long-term stay in a nursing home.
Providing daily care for older adults and people with disabilities is an important skill. However, those who provide custodial care are not technically trained doctors or medical professionals.
Read more about Medicare coverage for skilled nursing facilities.
Which parts of Medicare cover nursing homes?
Various parts of Medicare may assist with nursing home costs. The following table describes what Medicare may cover.
Medicare Part | Coverage |
covers in-hospital treatment, but it may also cover short-term care in an SNF, including medications. | |
covers outpatient services. It does not usually provide funding for stays in nursing homes. | |
does not usually cover long-term custodial nursing home care. However, coverage often depends on the company providing the plan, so exceptions may exist. | |
covers the cost of some or all of the prescription drugs for people who live long-term in a custodial nursing home. | |
These optional plans do not pay for long-term nursing home care. | However, Medigap plans may help cover some out-of-pocket costs. |
Medicare Part A nursing home coverage
If a person is recovering from an illness, accident, or medical procedure, Medicare Part A could provide coverage for a stay in an SNF.
A doctor must verify that the person requires daily skilled nursing care. The person must also have days left in their benefit period.
Part A covers up to 100 days of SNF care in each benefit period. If an individual needs to stay longer, they would not be eligible for further coverage.
They must also:
choose a Medicare-certified SNF
enter the SNF after a hospital stay of more than 3 days
receive skilled care for the original health problem for which they received treatment in the hospital or for a condition that developed while they were in the hospital
Here are some services that Medicare Part A may cover in an SNF:
a semiprivate room, which usually means that the person shares with one other individual
ambulance transportation to providers of healthcare services that the SNF does not provide
dietary counseling and nutrition services
meals
medical social services
medical supplies and equipment
medications
occupational therapy
physical therapy
skilled nursing care, such as intravenous injections
speech-language pathology
swing bed service, which means that an individual receives SNF care in an acute care hospital
These are the payments due for short-term SNF care in 2024:
Days 1–20: Medicare covers the full amount. The insured person pays nothing for each benefit period.
Days 21–100: The insured person pays a $204 coinsurance per day for each benefit period.
Days 101 and beyond: The insured person must pay the full costs.
If a person needs services that Medicare does not cover, they may have to pay more.
Medicare Part C nursing home coverage
Medicare Part C (Medicare Advantage) may pay for healthcare or prescription medications while a person stays in a nursing home. A Special Needs Plan (SNP) can help people with certain conditions or healthcare needs.
An individual should contact the plan provider directly for information on which services Medicare Advantage plans cover and which copay charges may apply.
Medicare Part D nursing home coverage
Medicare Part D can help someone cover prescription drugs while they live in a nursing home, according to the Centers for Medicare & Medicaid Services (CMS).
A long-term care pharmacy that works with the Medicare plan provides the medications.
Medigap and nursing home coverage
Private insurance companies offer Medigap policies to supplement Original Medicare (Parts A and B).
For an extra monthly premium, Medigap helps reduce out-of-pocket costs, such as copayments and deductibles, that original Medicare does not cover.
Medigap generally does not cover long-term care. However, it can help cover the daily coinsurance for days 21–100 of SNF care.
Federal law defines 10 Medigap plans. Some of them may help a person pay for the SNF coinsurance. However, individual states regulate the plans, and a person cannot obtain all the plans in each state.
How to fund nursing home care
Most people who live in a nursing home will need to pay for their care out of pocket from private resources.
The Medicaid program may help people with limited resources who need a nursing home. However, not all nursing homes accept Medicaid payments.
An individual’s Social Security benefit will not help with nursing home costs.
However, some older adults may qualify for supplemental security income in addition to Social Security, which could help fund nursing home care. A person can find out if they are eligible for this needs-based program by researching the Social Security disability program.
Private insurance companies offer long-term care policies that can pay for skilled and non-skilled care. The terms of these policies may vary depending on the provider. Some may cover nursing home care. Others include coverage for a range of medical services.
An existing life insurance policy may also provide cover for long-term care.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Summary
Medicare Part A can cover some costs associated with skilled nursing care in a nursing home if an individual meets specific requirements.
If a person needs long-term custodial care in a nursing home, they must pay out-of-pocket expenses. Medicaid or long-term care insurance may help with the costs.
View the original article on Medical News Today
