Medicare and Nursing Home Care

Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period when the stay is medically necessary and follows a qualifying three-day inpatient hospital stay. Keep in mind that this is different from nursing home care that is considered custodial care, where a person is assisted with daily tasks such as dressing and bathing. Custodial care, or personal care, is not covered by Medicare if it’s the only type of care you need. Most nursing homes provide this type of care, also known as long-term care, and you’ll have to pay the full cost for this type of care.

What services does Medicare cover in a skilled nursing facility?

Medicare Part A covers these services while you’re in a skilled nursing facility:

• A semi-private room
• Meals
• Skilled nursing care
• Physical therapy, occupational therapy, and speech-language pathology (covered if medically necessary to meet your health goals)
• Medical social services
• Medications, medical supplies, and equipment used in the skilled nursing facility
• Ambulance (if other transportation could endanger your health) to the nearest supplier of needed services not available at the skilled nursing home
• Dietary counseling

Non-essential services from nursing homes are not covered.

Your benefit period begins the day you start using your skilled nursing facility benefits under Medicare Part A. You can get up to 100 days of skilled nursing facility care in one benefit period.  If you use up these benefits or if you stop getting skilled nursing facility care for more than 30 days, your benefit period must end and you must have another three-day qualifying hospital stay to get coverage to get another 100 days of skilled nursing facility coverage.

Your benefit period can also end once 60 consecutive days have passed since you were in a hospital or skilled nursing facility, or you haven’t received skilled nursing care in the facility for 60 consecutive days. If you leave the skilled nursing facility but get re-admitted within 30 days, you may not need another qualifying three-day inpatient stay.

What are the requirements for Medicare to cover skilled nursing care?

Skilled nursing facility care is covered under Medicare Part A (hospital insurance) when the following conditions are met:

• You must have Medicare Part A.
• You must have days left in your skilled nursing facility benefit for the benefit period (Medicare Part A includes 100 days of this benefits).
• Medicare beneficiaries must first be an inpatient in a hospital for three consecutive days before entering the skilled nursing home. The qualifying inpatient hospital stay begins the first day you’re admitted to the hospital but does not include the day of discharge. Keep in mind any time you spend in the hospital under observation services (even if you stay overnight) doesn’t count towards your three-day qualifying inpatient stay; you must be formally admitted to the hospital as an inpatient. If you’re beginning a new Medicare benefit period of 100 days of skilled nursing facility coverage, then you must repeat the three-day qualifying hospital stay to meet the requirements for Medicare Part A skilled nursing home benefit.
• A doctor must determine that the skilled services are medically necessary, needed on a daily basis, and cannot be provided outside a skilled nursing facility. The skilled care that the nursing home provides and that you needs must have been part of the treatment during the qualifying three-day hospital stay or it must be to treat a condition that developed while you were being treated in the hospital or skilled nursing facility
• The skilled nursing services of the nursing home must be considered reasonable and necessary by Medicare.
• The skilled nursing facility must be Medicare-certified for Medicare to cover the services.

Getting more coverage for nursing-home care

Other Medicare coverage options could potentially increase your coverage when it comes to nursing homes.

• Medicare Supplement insurance: Some Medigap plans will help pay for Medicare coinsurance associated with care in a skilled nursing facility.
• Medicare Advantage (Medicare Part C) plans: Medicare Advantage plans are offered through Medicare-contracted private insurance companies. These plans must offer at least the same amount of coverage as Original Medicare, Part A and Part B, but some can offer additional benefits beyond that coverage. Medicare Advantage plans could cover nursing homes, and some may only cover them when the nursing homes have a contract with the Medicare Advantage plan. Since benefits vary by plan, be sure to contact the specific Medicare Advantage plan you’re interested in for more information.

Nursing homes and Medicare Part D

Medicare Part D is prescription drug coverage. If you live in a nursing home or other type of long-term care facility, long-term care pharmacies contract with Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans to cover your prescription medications. As mentioned above, Medicare Part A covers prescription drugs you need during a short-term stay in a skilled nursing facility; these tend to be the type of medications that need to be administered by a registered nurse or doctor, such as intravenous drugs.

Medicare beneficiaries who move into or move out of a nursing home or other institution can change Medicare drug plans at that time. You can change Medicare drug plans at any time while you’re living in the institution. You’ll have an ongoing Special Election Period that you can use to enroll in or disenroll from a Medicare Prescription Drug Plan or Medicare Advantage plan (in applicable states and subject to state-specific eligibility rules); if you’re already enrolled in a Medicare plan, you can use this Special Election Period to switch plans as well. This period does not end until two months after the month you move out of the institution. You don’t need to wait until the next Annual Election Period to make changes to your coverage.

Visit Medicare.gov’s Nursing Home Compare tool to learn more about Medicare coverage of nursing homes. Do you have questions about Medicare plan options that may fit your health needs? Feel free to give us a call at the phone number on this page to speak with a licensed insurance agent.