Will Medicare cover your expenses if you go to a nursing home for recovery after hospitalization?
The answer is, “It depends.” Medicare will only pay for skilled nursing care for a limited time, for specific needs and for certain conditions.
Less than 1 in 20 Medicare beneficiaries qualify for care in a skilled nursing facility, for an average stay of 25 days of care per admission.1
Medicare does not cover long-term care, whether in any nursing facility or your own home.
What Is Custodial Care versus Skilled Nursing Care?
Nursing homes mostly offer custodial care. You receive help with daily activities, such as bathing, eating, and dressing. Activities of Daily Living (ADL) is the term used in the industry to refer to such activities, and help with ADLs can be provided by informal caregivers, such as family and friends, or formal caregivers who are associated with a formal service system, like a home health agency. Help with ADLs is not provided by doctors and nurses.
Medicare does not cover custodial care. But Medicare Part A (hospital insurance) will cover medically necessary care that requires skilled nursing care or therapy. You must receive it at one of the over 15,000 Medicare-certified nursing facilities in the U.S.2 A beneficiary can also receive skilled nursing care or therapy at home, as home health care, discussed later.
A skilled nursing facility (SNF) offers more medical services than a traditional nursing home or assisted living facility. A facility may provide both skilled nursing care and custodial care. You will receive care from a qualified technician or health professional. For example, a registered nurse may inject medicine into your body intravenously.
If you qualify, Medicare will pay part of the cost for up to 100 days, depending on need. Covered services include:
- A semi-private room
- Skilled nursing care
- Physical, occupational or speech therapy
- Medications, supplies, and equipment
Who Benefits From Skilled Nursing Care?
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). They make up the foundation of all Medicare coverage, whether you receive it directly from Medicare or through Medicare Part C (Medicare Advantage).
Like most Medicare beneficiaries, you may receive Part A at no cost at 65 if you already have received or are eligible for benefits from Social Security based on your or your spouse’s work record. You may also qualify if you are under 65 and receive Social Security disability benefits for 24 months, or if you have end-stage renal disease (ESRD) and you meet certain requirements.
Through Original Medicare, short-term skilled care is provided in a Medicare-certified skilled nursing facility, as mentioned above. Under certain circumstances, it is also available as home health care.
You can get home health care if a doctor creates a care plan that requires limited skilled nursing care. Your doctor must certify that you are homebound, and a Medicare-certified home health agency must provide the services.3
For skilled nursing care with Medicare Advantage, you must check the terms in the Evidence of Coverage documentation received from your health plan before each plan year. Your plan may have lenient requirements to cover a stay in a skilled nursing facility, but it may require prior authorization. Whether a facility is in-network or out-of-network affects how services are covered.
Even if you have Medicare Part D (Prescription Drug Plan) coverage, Part A will generally cover prescriptions if they’re part of approved SNF care.4
How Does Skilled Nursing Care Work?
Medicare will pay for inpatient care at a Medicare-certified skilled nursing facility if you meet all these criteria:5
- You have Medicare Part A and days left in your benefit period (explained below).
- You were admitted as an inpatient at a hospital and stayed for three or more qualifying calendar days. Outpatient and observation days do not count. The three days start the day the hospital admits you as an inpatient; the discharge day does not count.
- You enter the skilled nursing facility within 30 days of being discharged from the hospital.
- A doctor ordered skilled nursing care for you that requires qualified personnel to administer or supervise it.
- You need specialized daily care you can only receive at a skilled nursing facility as an inpatient.
- You need follow-up care for a medical condition treated during your hospital stay. The condition can differ from the original reason for admission.
- The skilled services your doctor prescribed are reasonable and necessary for the diagnosis or treatment of your condition.
Some common reasons why a beneficiary may go to a nursing facility and not meet all criteria for Medicare payment are:
- they were not formally admitted in the hospital as an inpatient, but were there under observation, which does not count towards a qualifying hospital stay;
- they counted their discharge date as one of the three days required for the hospital stay; or
- they waited longer than 30 days from their hospital discharge to enter the nursing facility.
Medicare measures your use of hospital and skilled nursing facilities in “benefit periods.” It starts the day you are admitted to the hospital or facility as an inpatient. It ends when you have had no inpatient care in 60 consecutive days. The next time you enter a hospital or facility as an inpatient, a new benefit period begins. Your inpatient hospital deductible (if any) will come due at the start of each benefit period. You can have unlimited benefit periods.6
Why Skilled Nursing Facility Care Benefits Consumers
Inpatient care in a skilled nursing facility can run in the thousands or tens of thousands. If all the criteria listed above are met, Medicare beneficiaries can get Part A coverage for this kind of care and pay cost-sharing that is much lower than without Part A coverage.
If you qualify, Original Medicare pays the following per benefit period:7
- Days 1-20: 100%.
- Days 21-100: All but $176.00 (your daily copayment, or contribution to cost-sharing).
- Beyond 100 days: 0%.
(The cost-sharing will be different for beneficiaries of Medicare Advantage plans.)
If you have additional insurance, such as a Medicare Supplement (Medigap) policy, it may cover some of the costs Medicare does not. But it will not cover additional time at the skilled nursing facility beyond the 100 days Medicare covers.8
Even then, almost 90% of skilled nursing facility costs following hospitalization fall on patients or their families, according to Genworth Financial, an insurance company.9
What Else Should I Be Aware Of?
Check if you were admitted as an inpatient. If the hospital classified you as ‘Observation Status,’ which is an outpatient category, the hospital should have given you a Medicare Outpatient Observation Notice (MOON) and orally explained the status and how it might affect the cost of your stay. Whether you were an inpatient or outpatient in the hospital affects whether Medicare will cover your nursing home stay.
What Are Other Payment Options?
If Medicare will not pay for rehabilitative care or long-term care in a nursing home or elsewhere, your alternatives include:
Private payment: You or your family may opt to pay for such care out of pocket. The national average cost for a private nursing home room is $280 a day. This rate ranges from $185 in Oklahoma to $994 in Alaska.10 Once you sell off all assets and exhaust all your financial resources, you can turn to Medicaid to help pay for nursing home care.
Medicaid: Medicaid pays a large portion of U.S. nursing home bills. States administer this federal needs-based program for residents who lack resources for medical needs. You must qualify financially and medically. Eligibility varies by state but requires limited income and assets. You can contact your State Health Insurance Assistance Program about eligibility.
Long-term care insurance: If you have long-term care insurance and your policy covers it, you may use it for nursing home care. Check the terms of your contract for any elimination or waiting periods and for the amount of your daily benefit.
Veterans Administration: If you have VA health benefits, you may inquire how you can access long-term care benefits from the U.S. Department of Veterans Affairs.
Could Nursing Home Care Be Right for Me?
If you need a place to recuperate and get specialized care, a skilled nursing facility could be the solution. But it’s also a costly one.
With Medicare Part A, you can receive at least partial coverage for up to 100 days. Make sure to familiarize yourself with Medicare’s rules and regulations to get the care you want. If you qualify, Medicare has a tool on its website to help you locate a nursing home.