The critical difference between skilled and custodial care
To understand Medicare's policy on nursing home care, it's essential to differentiate between skilled care and custodial care. This is the central factor that determines what is covered and for how long.
Skilled nursing care
Skilled care refers to daily medical services that require the skills of licensed professionals, such as a registered nurse or physical therapist. Medicare Part A may cover this type of care for a short period in a skilled nursing facility (SNF) under specific conditions.
Common examples of skilled care covered by Medicare include:
- Physical, occupational, or speech therapy
- Intravenous (IV) injections
- Wound care for serious injuries
- Rehabilitation services after an illness, injury, or surgery
Custodial or long-term care
In contrast, custodial care is non-medical assistance with daily living activities (ADLs), and it is not covered by Original Medicare. Most nursing home stays fall into this category. If the only care a person needs is help with basic personal tasks, Medicare will not pay for it.
Examples of custodial care not covered by Medicare:
- Help with bathing and dressing
- Assistance with eating
- Using the bathroom
- Supervision for someone with cognitive decline, such as dementia
Medicare Part A conditions for skilled nursing facility coverage
For Medicare to cover a stay in a skilled nursing facility, several strict requirements must be met. If these are not followed precisely, the beneficiary will be responsible for the full cost of the stay.
The requirements include:
- A qualifying hospital stay: The patient must have been admitted as an inpatient for at least three consecutive days before entering the SNF. Time spent under 'observation status' in a hospital does not count.
- Admission timing: Admission to the skilled nursing facility must occur within 30 days of leaving the hospital.
- Daily skilled care need: A doctor must certify that the patient needs daily skilled nursing or rehabilitation services related to the condition treated during the hospital stay or a new condition that developed while in the SNF.
- Medicare-certified facility: The services must be received in a facility that is Medicare-certified.
Coverage timeline and costs for skilled care
Even when all conditions are met, Medicare's coverage for skilled nursing facility stays is limited in duration. Your out-of-pocket costs will depend on how long you need care.
| Length of Stay in a Skilled Nursing Facility (per benefit period) | Medicare Part A Coverage | Your Out-of-Pocket Cost (2025 rates) |
|---|---|---|
| Days 1–20 | Full coverage | $0 |
| Days 21–100 | Partial coverage | Up to $209.50 per day in coinsurance |
| Day 101 and beyond | No coverage | All costs |
A new benefit period can begin if you are discharged from the SNF and stay out for at least 60 consecutive days, then meet the qualifying criteria again for a new hospital stay. However, this is not a reliable long-term strategy for extended care. Additionally, the daily coinsurance for days 21-100 can add up to a significant out-of-pocket expense.
Paying for long-term custodial care
Since Medicare will not pay for the long-term custodial care most seniors in nursing homes need, other payment methods must be considered. Planning ahead is crucial to avoid depleting personal savings.
- Medicaid: This is the most significant public option for long-term care. It is a joint federal and state program for people with limited income and resources. Eligibility rules vary by state, but Medicaid typically covers 100% of nursing home costs for those who qualify. However, individuals often must contribute most of their income to their care and may be required to 'spend down' their assets to qualify.
- Long-Term Care (LTC) Insurance: Private LTC insurance policies are designed specifically to cover long-term care services, including custodial care. Policies vary widely, with coverage options for care at home, assisted living, and nursing homes. Premiums are often based on age and health at the time of purchase, making it more affordable for those who buy it earlier in life.
- Medicare Advantage (Part C): These are private, Medicare-approved plans. While they must cover all services included in Original Medicare, some plans offer supplemental benefits that may include limited long-term care services. However, they generally do not cover room and board for a long-term nursing home stay.
- Medicare Supplement (Medigap): Medigap policies help pay for the out-of-pocket costs of Original Medicare, such as coinsurance and deductibles. Some plans will cover the daily coinsurance for skilled nursing care from day 21 through 100. Crucially, they do not cover long-term custodial care.
- Personal Savings: Many people pay for nursing home care out-of-pocket using savings, retirement accounts, or other personal assets, a strategy sometimes referred to as 'private pay'.
Conclusion
For seniors, the question of does Medicare cover a nursing home for seniors hinges on the type of care needed. While Medicare Part A offers limited, short-term coverage for skilled medical care following a qualifying hospital stay, it does not cover the long-term custodial care that most residents in nursing homes require. For extended needs, alternatives like Medicaid, private long-term care insurance, or personal savings must be considered. Families should research and plan for these costs well in advance to ensure their loved ones receive the necessary care without facing unexpected financial burdens. The official Medicare website (www.medicare.gov) provides comprehensive resources and is the most authoritative source for details on coverage limitations.
