Many who stay at nursing homes are there to receive help with their activities of daily living, like going to the bathroom, preparing a meal, or getting dressed. These aren’t skilled medical services, so Medicare doesn’t foot the bill. However, if you’re in a nursing home and receiving medical care, such as getting your wound dressings changed or receiving physical therapy, then Medicare might cover your stay.
Medicare also covers short-term stays at skilled nursing facilities. You live at a skilled nursing facility just like at a nursing home, but the focus is solely on medically necessary treatment from professionals.
Table of Contents
Long-term Care a Reality For Many
Long-term care is a common problem many older adults and those with disabilities face. Whether you cannot care for yourself due to an injury or illness, having someone to help you make it through the day can improve your quality of life.
Unfortunately, long-term care isn’t cheap. The average daily cost for a semi-private room in a nursing home is $225 — or $6,844 per month. If you wanted to upgrade to a private room, the average cost goes up to $253 a day and $7,698 a month. Even if you’re able to live at home and just need someone to stop by for a few hours, it can be around $20 an hour for a health aide or homemaker service. Medicare can help pay for some of these care costs.
How Does Medicare Nursing Home Coverage Work?
To receive Medicare nursing home coverage, you must have a condition requiring skilled care. For covered stays, you use your Medicare Part A benefits. You don’t pay anything for the first 20 days of your stay. If you stay between 21 and 100 days, you pay up to $200 a day in coinsurance. After that, you pay the costs on your own.
During your stay at a nursing home, Medicare covers expenses like meals, skilled nursing care, physical and occupational therapy, and even ambulance transportation. Often, you’re given a semi-private room to share with others.
Medicare coverage for a skilled nursing facility hinges on a few factors, including:
- You have enough Part A days left in your benefit period.
- You’ve had a qualifying inpatient hospital stay.
- Your doctor says you require daily skilled care.
- You’re staying at a Medicare-certified skilled nursing facility.
- You have either a medical condition that was treated during a 3-day hospital stay or one that developed during your stay in a skilled nursing facility. You may not need a 3-day minimum inpatient hospital stay if your doctor participates in an Accountable Care Organization (ACO).
How Part A Covers Skilled Nursing Home Care
Medicare Part A covers hospital and inpatient stays, so it covers the majority of your nursing home care expenses. For example, if your doctor orders you skilled nursing care to manage a wound at the facility, Part A covers this. Other things that are covered might include:
- Physical therapy
- Occupational therapy
- Speech-language therapy
- Dietary counseling
- Medical supplies and equipment you use during your stay
Skilled Nursing Facility Stays
A skilled nursing facility is a step down from the hospital but a step above a nursing home. In a skilled nursing facility, you receive care from registered nurses and other health professionals as you recover from an injury or illness.
If you’re staying in a Medicare-certified skilled nursing facility and meet the eligibility requirements, Medicare doesn’t charge you for the first 20 days of your stay. Between days 21 and 100, you have to pay the coinsurance; after that, the costs are on you.
Home Health Care
If you’re well enough to go home after a hospital stay, your doctor might prescribe home health care. This is when nurses or therapists visit your home at set intervals to check up on you and ensure you’re healing.
Medicare covers home health care expenses 100%. However, you must be recertified every 30 days based on your condition. Also, if you need medical equipment at home, you pay 20% coinsurance after you meet your Part B deductible.
How Part B Covers Nursing Home Care
Medicare Part B is the portion of your insurance that pays for outpatient services, such as doctor’s visits and health screenings. Usually, it’s not involved with nursing home care, as that’s an inpatient stay. However, you may use your Part B insurance for ambulance transportation to and from the facility or durable medical equipment.
For many of Part B’s services, you have to pay the deductible of $240 before coverage kicks in. After that, you pay 20% of the costs.
Excluded From Medicare Coverage
There are some expenses that Medicare doesn’t cover in a nursing home. Because Medicare is a medical insurance, it focuses on medical costs. Additionally, Medicare is meant for short-term care — that’s one of the reasons Medicare only covers your first 20 days of a stay at 100%. Here’s a look at two other types of nursing home care that Medicare does not cover.
Many nursing homes provide custodial care — care that’s not medically necessary. It can include things like help with bathing, dressing, or tidying up around the house. Medicare doesn’t cover this because non-licensed caregivers can safely provide it.
Adult Day Care
Adult daycare centers help older adults who need assistance during the day. They’re ideal for primary caregivers who must go to work or deal with other responsibilities. While here, adults receive social and recreational support — but no medical care; therefore, Medicare does not pay for this service.
Nursing Homes vs. Skilled Nursing Care
While nursing homes and skilled nursing care can help older adults recover after an illness or injury, they’re very different — especially regarding how Medicare handles them.
Nursing homes are primarily for people who require long-term care and need help with activities of daily living. You may go there if you don’t have a dedicated caregiver to help you around the house. While you may be able to get skilled nursing care at a nursing home, that’s not the facility’s sole purpose.
Skilled nursing care, on the other hand, is when you receive help for a medical condition. It typically takes place in a skilled nursing facility. There are always nurses on staff to monitor your progress, administer medications, and tend to your needs. Skilled nursing care is usually temporary, and you usually need it after recovering from an injury or illness.
How Much Does Medicare Cover Skilled Nursing Home Care?
Amount You Pay
Semi-private room (first 20 days)
Semi-private room (days 21-100)
$200 per day
Semi-private room (day 101+)
Ambulance ride to the skilled nursing facility
20% (after you meet the $240 deductible)
Home health care
How Do Other Medicare Options Cover Nursing Home Care?
You have options other than Original Medicare (Medicare Part A and Part B) for paying for nursing home care. A few other Medicare plans might pay for some of your stay. For example, Medicare Advantage (also known as Part C) plans offer similar coverage. Medicare supplement plans and Medicare Part D can also help with the bills.
How Medicare Advantage Covers Nursing Home Care
Medicare Advantage is coverage provided by third-party insurance companies. It combines your Part A and Part B benefits into one and sometimes offers additional benefits. While each plan can charge different out-of-pocket costs and offer varying amounts of coverage, they have to follow rules set by Medicare. Your plan might provide similar coverage to Original Medicare for a nursing home care stay. Custodial and long-term nursing home care likely aren’t covered, but skilled nursing care may be. Check with your plan’s specific details to know what is and isn’t covered in your specific instance.
How Medicare Supplement (Medigap) Covers Nursing Home Care
Private insurance companies sell Medigap plans to help you pay for costs not covered by Original Medicare. Plans C, D, F, G, M, and N cover 100% of your skilled nursing facility coinsurance bills. Plan K covers 50% of them, while Plan L covers 75%.
As an example, imagine you stay at a skilled nursing facility for 30 days. You would owe $200 a day for days 21 to 30 — a total of $2,000. Plans C, D, F, G, M, and N cover this bill for you. With Plan K, you would pay $1,000, and with Plan L, you would pay $500.
How Medicare Part D Covers Nursing Home Care
Medicare Part D specifically covers prescription drug coverage, so it doesn’t cover your nursing home care. When you’re at a skilled nursing facility, your prescription drugs are usually covered by Medicare Part A. However, Part D can cover the cost of medications you receive at a nursing home.
As an example, imagine you’re a person with diabetes who’s living at a nursing home. Medicare Part D does not pay for your stay at the nursing home. However, it can pay for the insulin you need every month.
Alternatives to Help Pay For Nursing Homes
If you or a loved one must transition to long-term nursing home care, options outside of Medicare can help offset some costs. It pays to consider your options before committing to long-term care.
Every state has slightly different regulations for what Medicaid does and does not cover. However, according to federal requirements, programs must cover skilled nursing care, rehabilitation, medically related social services, and pharmaceutical services. Additionally, basics like meals, a semi-private room, and hygiene services must be provided at no cost. Check with your local Medicaid agency for more details on what offerings are available to you.
Long-term Care Insurance
Long-term care insurance is specifically meant to cover the costs of long-term care. This includes both personal and custodial care — 2 things Medicare and many traditional insurances do not cover.
Typically, long-term care insurance works by reimbursing you a daily amount for services you receive at a nursing home. You can usually customize your policy to decide what it does and doesn’t include. Additionally, many policies have a limit to how long or how much they pay.
If you have Veterans Affairs (VA) benefits, you may have access to 3 types of VA care: community living centers, community nursing homes, and state veterans homes. These facilities cover expenses like 24/7 nursing care, physical therapy, and custodial care. Generally, the VA pays for some of these services, but you may still need to pay a copay.
If you aren’t eligible for any of these other alternatives, you may need to use your personal savings to pay for long-term care. For older adults transitioning permanently into long-term care, you may be able to get some extra money by selling or renting your home. It’s also possible to pull from their 401(k) or IRA and use that money to pay for nursing home services.
Putting It All Together
Long-term care in a nursing home is an expensive cost. However, Original Medicare might pay for some of your stay if you need skilled nursing care and meet the other eligibility requirements. If it does not, you have a few other options for footing the bill, including Medicare Advantage, Medigap, and Part D plans. Medicaid, long-term care insurance, and VA benefits could also provide coverage.
There are ways to save, even if you have to pay for your care with your personal savings. For instance, opt for a semi-private room and look for nursing homes without many additional amenities to keep your bill lower.