Does Medicare Pay for Nursing Home Care?
- Medicare Part A and Medicare Advantage plans can help cover costs of stays in a skilled nursing facility up to 100 days. Learn more about how and when Medicare covers nursing care, and find out how much it may cost.
Medicare coverage is not always easy to understand and often comes with numerous exceptions, conditions and qualifying criteria.
Nursing home care is one of those complex areas. Medicare does cover nursing home care in certain situations. In this guide, we break down Medicare nursing home coverage in a clear and concise way.
Skilled Nursing Care vs. Custodial Care
An important aspect to understand about Medicare nursing home coverage is the difference between skilled nursing care and custodial care.
- Skilled nursing care refers to the duties that can only be performed by a licensed professional, such as physical therapy, medicine shots, medical evaluations and other types of treatment.
Skilled care provided in a skilled nursing facility (SNF) is covered by Medicare. Custodial care may also be covered is a Medicare, but only if the beneficiary is also receiving skilled nursing care.
- Custodial care, or personal care, refers to assisted living tasks such as bathing, dressing, eating, toileting and moving from a bed to a chair or to other parts of a room or home.
If you stay in an assisted living center or a nursing home and custodial care is the only type of care you need, Medicare won’t cover the costs of your care. Many nursing home stays may involve custodial care, and those services not covered by Original Medicare (Part A and Part B).
It’s important to note that some Medicare Advantage plans may cover more services than Original Medicare covers. If you have a Medicare Advantage plan, be sure to check with your plan carrier directly to find out if your plan offers any nursing home care coverage or assisted living benefits.
How Many Days Will Medicare Pay for Skilled Nursing Care?
Medicare covers up to 100 days of care in a skilled nursing facility if you meet the following criteria:
- You must have Medicare Part A or a Medicare Advantage plan.
- You must have unused days remaining in your benefit period.
- You have a qualifying hospital stay of at least three days and are admitted to the skilled nursing facility within 30 days of your hospital discharge.
- You need the skilled nursing services for a medical condition that was treated (or treatment was started) during your hospital stay.
- Your doctor determines that you need daily skilled care.
- You receive nursing care services at a facility that’s certified by Medicare.
What Types of Skilled Nursing Health Care Services Are Covered by Medicare?
Medicare can cover the following services (and possibly more) during skilled nursing facility stays:
- Semi-private room
- Skilled nursing care
- Physical therapy
- Occupational therapy
- Speech language pathology services
- Medical social services
- Medical supplies and equipment
- Ambulance transportation to the nearest provider of necessary services when not available at the skilled nursing facility
- Dietary counseling
- Swing bed services
Skilled nursing facility care is covered by Medicare Part A and by Medicare Advantage plans.
A Medicare Part D prescription drug plan (or a Medicare Advantage plan that includes Part D drug coverage) can cover some of the prescription drugs you take during your nursing facility stay.
What Does Medicare Pay for Long Term Care?
So how much can you expect to pay for long term care and skilled nursing care under Medicare?
- Medicare covers the first 20 days of skilled nursing facility care during each benefit period in full, with no coinsurance costs.
- Days 21 through 100 of your benefit period require a daily coinsurance payment of $185.50 per day in 2021. If your stay lasts longer than 100 days, Medicare doesn’t pay any additional costs.
It’s worth noting that the days do not need to be consecutive, they just need to be in the same benefit period.
For example, let’s say you stayed in a skilled nursing home for 12 days and were then released home. You were later re-admitted to the hospital and back to the skilled nursing facility again, this time for 10 days. As long as both stays came during the same benefit period, you have now reached 22 days of skilled nursing facility care and will be responsible for the daily coinsurance payment for the final two days of your second stay.
Once your benefit period resets, so do your accumulated days of skilled nursing facility stays.
Medicare Supplement Insurance plans, also called Medigap, can help cover skilled nursing facility care coinsurance costs either partially or in full, depending on the type of Medigap plan.
Skilled nursing facility care is also covered by Medicare Advantage, and costs will vary by plan.