Will Medicare cover your expenses if you go to a nursing home for recovery after hospitalization?
The answer is yes but with some caveats. Medicare will only pay for nursing home care for a limited time, for specific needs and for certain conditions.
Less than 1 in 20 Medicare beneficiaries qualify for care in a nursing home, 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 Nursing Home Care?
Nursing homes mostly offer custodial care. You receive help with daily activities, such as bathing, eating, and dressing, that do not require professional training.
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 also receive it at one of the over 15,000 Medicare-certified nursing facilities in the U.S.2
A skilled nursing facility (SNF) offers more medical services than a traditional nursing home or assisted living facility. 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).
You receive Part A at no cost if over 65 and can receive Social Security.
Through Original Medicare, short-term skilled care is provided in a Medicare-certified nursing home or with 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 you cannot leave your house; a Medicare-certified home health agency must provide the services.3
With Medicare Advantage, you must check the terms for skilled nursing care with your plan provider. Your policy may have more lenient requirements, 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 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 stayed at a hospital as an inpatient 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 date does not count.
- You enter the skilled nursing facility within 30 days of being discharged.
- A doctor ordered you to receive skilled nursing care that requires qualified personnel to administer or supervise it.
- You need specialized daily care l 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.
Medicare measures your use of hospital and skilled nursing facilities in “benefit periods.” It starts the day you enter 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 Nursing Home Care Benefits Consumers?
Inpatient care in a skilled nursing facility can run in the thousands or tens of thousands. Part A coverage makes this kind of care accessible to many who could not afford it.
If you qualify, Medicare pays the following per benefit period:7
- Days 1-20: 100%.
- Days 21-100: All but $176.00 (your daily coinsurance, or contribution to cost-sharing).
- Beyond 100 days: 0%.
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 a patient. If not, the hospital may have classified you as under observation. This could affect your ability to get skilled nursing care after discharge.
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:
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 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.
If you served in the military, you may receive financial assistance from the U.S. Department of Veterans Affairs.
Long-term care insurance
If you have long-term care insurance, 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.
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 partial to full coverage for up to 100 days. Make sure to familiarize yourself with Medicare’s rules and regulations to get the care you want.