Medicare and Nursing Homes

Medicare Coverage of Nursing Homes

Within a benefit period, Medicare Part A covers up to 100 days of skilled nursing facility care given in nursing homes. A benefit period starts the day you start using your nursing homes benefits under Medicare Part A. If you use up your nursing homes benefit, you must have another 3-day qualifying hospital stay to get coverage for another 100 days of nursing homes coverage.

Medicare Covers Services in Nursing Homes

The following services are covered by Original Medicare when provided in nursing homes:

• Semi-private room
• Meals
• Skilled nursing care
• Physical therapy, occupational therapy, speech-language pathology
• Medical social services
• Medications, medical supplies and equipment used in nursing homes
• Ambulance to nearest supplier of needed services not available at skilled nursing homes
• Dietary counseling

Non-essential services from nursing homes are not covered.

Required Conditions for Medicare Coverage of Nursing Homes

Nursing homes are covered under Medicare Part A (hospital insurance) when these conditions are met:

• You must have Medicare Part A.
• Medicare Part A includes 100 days of nursing homes benefits. You must have days left in your nursing homes benefit for the benefit year.
• Medicare beneficiaries must first be a patient in a hospital for 3 consecutive days before entering skilled nursing homes. This nursing homes qualifier begins the first day you're admitted to the hospital, but does not include the day of discharge. If you're beginning a new Medicare benefit year of 100 days of nursing homes coverage, then you must repeat the 3-day qualifying hospital stay to meet the requirements for Medicare Part A skilled nursing homes benefit.
• A doctor must order services that cannot be provided outside nursing homes.
• The skill that nursing homes can provide, and which the Medicare beneficiary needs, must have been part of the treatment during the qualifying 3-day stay.
• The skilled nursing services of the nursing homes must be considered reasonable and necessary by Medicare.
• Nursing homes must be certified by Medicare for Medicare to cover those nursing homes.

Medicare Out-of-pocket Costs for Nursing Homes

If covered by Medicare, you pay nothing for the first twenty days of Medicare nursing homes benefits. Medicare beneficiaries pay $141.50 per day (in 2011) in nursing homes for days 21 through 100. Medicare does not cover nursing homes beyond 100 days in a given Medicare benefits year.

Other Coverage Options for Nursing Homes

Check out other Medicare coverage options that may increase your Medicare coverage of nursing homes.

• Medicare Supplemental Insurance - Some Medigap plans will help pay for nursing homes beyond the Medicare limitations and coinsurance amounts.
• Medicare Advantage (Medicare Part C) plans - Medicare Advantage plans are private insurance, thus each plan is different. Many Medicare Advantage plans do cover nursing homes. However, some plans may cover nursing homes only when the nursing homes have a contract with the Medicare Advantage plan.

Costs of Nursing Homes that are Covered under Medicare Part D

Medicare Part D is prescription drug insurance. When medications are provided by the pharmacies within the nursing homes, or owned by nursing homes, Medicare will cover those costs. However, when the medications are dispensed by the staff within nursing homes, Medicare Part A covers those costs.

Visit www.medicare.gov/NHCompare/Home.asp to learn more about Medicare coverage of nursing homes.

Medicare has neither reviewed nor endorsed this information.