Does Medicare pay for nursing home care?

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As a general rule, Medicare Part A covers a person for 100 days of acute care in an SNF. Every day, the individual must receive 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.

Various parts of Medicare may assist with nursing home costs. Here is a summary of what Medicare may cover:

• Medicare Part A: This part of Medicare covers in-hospital treatment, but it may also cover short-term care in an SNF, including medications.
• Medicare Part B: Part B covers outpatient services. It does not usually provide funding for stays in nursing homes.
• Medicare Part C: Private companies administer this bundled plan, also known as Medicare Advantage. It does not usually cover long-term custodial nursing home care. However, coverage often depends on the company providing the plan, so exceptions may exist.
• Medicare Part D: Part D covers the cost of some or all of the prescription drugs for people who live long term in a custodial nursing home.
• Medigap: These optional plans do not pay for long-term nursing home care. However, Medigap plans may help cover some out-of-pocket costs.

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 semi-private 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:

• 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 $185.50 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 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 can help someone cover prescription drugs while they live in a nursing home, according to the Centers for Medicare & Medicaid Services. A long-term care pharmacy that works with the Medicare plan provides the medications.

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 in days 21–100 of SNF care.

Federal law defines 10 Medigap plans. Some of them may help a person pay for the SNF coinsurance, according to the Kaiser Family Foundation. However, individual states regulate the plans, and a person cannot obtain all the plans in each state.

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 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.