Medicare is a health insurance program for those ages 65 and older (and with certain medical conditions) in the United States.
The programs cover services like hospital stays and outpatient services and preventive care. Medicare may cover short-term stays in a nursing home when a person needs skilled care.
However, if a person wants to move to a nursing home long-term, Medicare plans usually will not cover this cost.
To understand what Medicare covers in a nursing home, it’s sometimes best to know what they don’t cover. Medicare doesn’t cover care in a nursing home when a person needs custodial care only. Custodial care includes the following services:
- going to the bathroom
As a general rule, if a person needs care that doesn’t require a degree to provide, Medicare doesn’t cover the service.
Now let’s look at what Medicare does cover.
requirements for medicare to cover CARE in a nursing home
Medicare does cover skilled nursing care in a nursing home facility, but you have to meet several requirements. These include:
- You must have Medicare Part A and have days left in your benefit period.
- You must have first had a qualifying hospital stay.
- Your doctor must determine you require daily, skilled nursing care.
- You must receive the care at a skilled nursing facility.
- The facility where you receive your services must be Medicare-certified.
- You need skilled services for a hospital-related medical condition or a condition that started while you were in a skilled nursing facility getting help for the original, hospital-related medical condition.
It’s also important to note this care is for a short-term basis, not for long-term care.
Usually, Medicare Part A may pay for up to 100 days in a skilled nursing facility. A skilled nursing facility must admit the person within 30 days after they left the hospital, and they must admit them for the illness or injury the person was receiving hospital care for.
Medicare usually only covers short-term skilled nursing care in a nursing home. Keep reading for a breakdown of what Medicare may cover related to nursing homes.
Medicare Part A
Some services Medicare Part A may cover in a nursing home environment include:
- dietary counseling and nutrition services
- medical supplies and equipment
- occupational therapy
- physical therapy
- semi-private room
- skilled nursing care, such as wound dressing changes
- social work services related to needed medical care
- speech-language pathology
Medicare may also cover something called “swing bed services.” This is when a person receives skilled nursing facility care in an acute-care hospital.
Medicare Part B
Medicare Part B is the portion of Medicare that pays for outpatient services, such as doctor’s visits and health screenings. This portion of Medicare doesn’t usually cover nursing home stays.
Do Advantage plans cover any part of it?
Medicare Advantage plans (also called Medicare Part C) don’t usually cover nursing home care that’s considered custodial care. A few exceptions exist, including if a person’s plan has a contract with a specific nursing home or organization that operates nursing homes.
Always contact your plan provider before going to a particular nursing home so you understand what services are and aren’t covered under your Medicare Advantage plan.
What about Medigap supplements?
Medigap supplement plans are sold by private insurance companies and help to cover additional costs, such as deductibles.
Some Medigap plans may help to pay for skilled nursing facility co-insurance. These include plans C, D, F, G, M, and N. Plan K pays for about 50 percent of the coinsurance and Plan L pays for 75 percent of coinsurance.
However, Medigap supplement plans don’t pay for long-term nursing home care.
What about Part D medications?
Medicare Part D is prescription drug coverage that helps pay for all or a portion of a person’s medications.
If a person lives in a nursing home, they’ll typically receive their prescriptions from a long-term care pharmacy that provides medications to those in long-term care facilities like a nursing home.
However, if you’re in a skilled facility receiving skilled nursing care, Medicare Part A will usually cover your prescriptions during this time.
Most Medicare plans won’t cover nursing home care. Exceptions may include if you purchase a Medicare Advantage plan with a specific agreement with a nursing home. Again, these are often the exception, not the rule, and available options vary geographically.
options to help pay for nursing home care
If you or a loved one may need to transition to long-term nursing home care, there are options outside of Medicare that may help offset some costs. These include:
- Long-term care insurance. This may help to pay all or a portion of nursing home costs. Many people will purchase these policies at a younger age, such as in their 50s, as the premiums usually increase in cost as a person ages.
- Medicaid. Medicaid, the insurance program that helps cover costs for those in low-income households, has state and national programs that help pay for nursing home care.
- Veterans Administration. Those who served in the military may be able to receive financial assistance for long-term care services through the United States Department of Veterans Affairs.
Some individuals may find they require Medicaid services after they exhaust their personal financial resources in paying for long-term care. To find out more on how to qualify, visit the State Health Insurance Assistance Programs network.
A nursing home is a place where a person can receive extra care services from nurses or nurses’ aides.
Many of these facilities may be homes or apartments for people who need extra care for their daily activities or who no longer desire to live alone. Some resemble hospitals or hotels with rooms with beds and baths and common spaces for classes, recreation, eating, and relaxing.
Most nursing homes provide around-the-clock care. Services can vary, but may include help to go to the bathroom, assistance getting medications, and meal services.
Financial organization Genworth tracked the cost of care in skilled nursing facilities and nursing homes from 2004 to 2019.
They found the average 2019 cost of a private room in a nursing home is $102,200 per year, which is a 56.78 percent increase from 2004. Care in an assisted living facility costs on average $48,612 per year, a 68.79 percent increase from 2004.
Nursing home care is expensive — these costs include care for increasingly sicker patients, employee shortages, and greater regulations that increase expenses all account for rising costs.
Tips for helping a loved one enroll in Medicare
If you have a loved one who is reaching age 65, here are some tips on how you can help them enroll:
- You can start the process 3 months before your loved one turns age 65. Starting early can help you get needed questions answered and take some stress out of the process.
- Contact your local Social Security Administration or find a location by visiting their official website.
- Visit Medicare.gov to find out about available health and drug plans.
- Talk to your friends and other family members who may have gone through a similar process. They can give you tips on what they learned through the process of signing up for Medicare and selecting supplement plans, if applicable.
Medicare Part A can cover skilled nursing care in a nursing home environment, providing a person meets specific requirements.
If you or a loved one desires or needs to live in a nursing home long-term to receive custodial care and other services, you’ll likely be required to pay out-of-pocket or utilize services like long-term care insurance or Medicaid.