Does Medicare Cover Nursing Home Care?  

Mike Olmos by Mike Olmos | Licensed since 2010

This article was updated on: 09/10/2018

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If you or a loved one needs nursing home care, you may have questions about Medicare coverage for your expenses. This article explains what costs Medicare will cover and what options are available for additional help.

What nursing home care does Medicare cover?

Nursing home care can be broken into two broad categories: Custodial care and skilled nursing care.

Custodial care

Custodial care is help with daily living activities such as eating, bathing, dressing, and toileting; this type of care is not usually eligible for Medicare coverage under Original Medicare (Part A and Part B). For help paying for custodial care, you have the option to purchase long-term care insurance from a private insurance company. Long-term care insurance may cover both skilled and unskilled care.

Skilled nursing care

Skilled nursing care can be provided by registered nurses, licensed practical and vocational nurses, physical and occupational therapists, and speech-language pathologists, among other skilled staff. . This might include sterile dressing changes and wound care, or physical, respiratory, or occupational therapy. These services are covered under Part A (hospital insurance) under certain conditions for a limited period of time when provided in a skilled nursing facility. To qualify for Medicare coverage, a qualifying stay must meet these requirements:

  • You must have had a qualifying hospital stay of three inpatient days or more
  • You must have days left in your Part A benefit period (Medicare may cover up to 100 days per benefit period).
  • Your doctor decides skilled nursing care is medically necessary to treat your condition.
  • You get the required skilled care on a daily basis.
  • Your nursing home stay is related to the condition you were treated for as an inpatient in the hospital or a new condition that started while you were getting nursing facility care for the ongoing condition.
  • Your nursing home care is provided in a facility certified by Medicare.

What nursing home care expenses will Original Medicare cover?

If you qualify, then Original Medicare may cover expenses related to your nursing home care in a skilled nursing facility for the first 100 days as follows: For days 1 to 20 of your stay during the benefit period, you pay $0. For days 21 to 100 of your stay, you pay $167.50 per day in 2018 as coinsurance. At day 101 and beyond, you are usually responsible for all expenses associated with your nursing home care.

How can Medicare Supplement Insurance plans help with nursing home care expenses?

A Medicare Supplement Insurance policy offered by a private company may help you pay for certain Medicare out-of-pocket costs, such as copayments, coinsurance and deductibles. Of the 10 Medicare Supplement plans offered in most states, eight cover skilled nursing facility care coinsurance at least 50% and some up to 100%. If you stayed in a skilled nursing facility for 50 days in 2018, you could be responsible for $5,025 which a Medicare Supplement plan may cover. However, Medicare Supplement plans generally don’t cover long-term care or private-duty nursing.

How can Medicare Advantage plans help with nursing home care expenses?

Some people choose to get their Medicare benefits through Medicare Advantage plans, an alternative way to receive Original Medicare (Part A and Part B) benefits. These plans must cover all services that Original Medicare covers (except for hospice care, which is still provided under Part A), but in many cases, they offer additional benefits such as coverage for prescription drugs that may help offset your nursing home care expenses. Keep in mind that you must still pay your Part B premium if you enroll in a Medicare Advantage plan. Because Medicare Advantage plans include Original Medicare (Part A and Part B) benefits, they must include at least the same coverage of skilled nursing care as described for Original Medicare above.

Where can I get help with nursing home care expenses?

If you need long-term nursing home care after Medicare coverage expires, your state may be able to help you through the Medicaid program. To see if you qualify for Medicaid assistance, contact your state Medicaid office or State Health Insurance Assistance Program (SHIP); this online tool from Medicare will help you find the office in your area.

You may also want to talk to your doctor about home health services as an alternative to a skilled nursing facility. Under certain conditions Part A and/or Part B may cover eligible home health services which could include intermittent skilled nursing care (less than 7 days a week or less than 8 hours a day). Home health services could also include physical therapy, occupational services and more.

If you still have questions about Medicare coverage for nursing home care, or would like more information about home nursing care, I’m happy to assist you. You can also request a phone call or email with information prepared just for you by clicking the appropriate link below. To see some plans in your area you may qualify for, click the “Compare Plans” button.

Benefits, copayments/co-insurance may change on January 1 of each year.

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