Does Medicare Pay for Long-Term Care in a Nursing Home? What You Need to Know

According to the U.S. Department of Health and Human Services, about 60% of people turning 65 will need long-term care at some point in their lives. While many assume their health insurance will cover it, the truth about whether Does Medicare pay for long-term care in a nursing home? is often misunderstood and requires careful planning.

Quick Summary

Medicare generally does not cover long-term custodial care in a nursing home, but it provides limited coverage for short-term, medically necessary skilled nursing care after a qualifying hospital stay. Other payment options exist, including Medicaid, long-term care insurance, and private funds.

Key Points

• Limited Medicare Coverage: Medicare does not cover long-term custodial care for help with daily living activities in a nursing home.

• Short-Term Skilled Care: Medicare Part A provides coverage for up to 100 days of medically necessary skilled nursing care, but only after a qualifying inpatient hospital stay.

• Custodial Care Exclusion: Assistance with non-medical tasks like bathing and dressing is considered custodial care and is not paid for by Medicare if it's the only care needed.

• Patient Coinsurance Required: After the first 20 days of an eligible stay, beneficiaries are responsible for a daily coinsurance payment for skilled care.

• Other Payment Options Are Necessary: For long-term stays, you must rely on other funding sources, including Medicaid (for those with limited income and assets), long-term care insurance, veterans' benefits, or private funds.

• Medicare Advantage Plan Variations: Medicare Advantage plans must cover the same skilled care as Original Medicare, but costs and rules may differ; always check with your plan.

• Medigap Fills the Gaps: Medigap plans can help cover the daily coinsurance costs for a skilled nursing facility stay but do not cover long-term custodial care.

Medicare and Nursing Home Care: A Limited Benefit

Many people are surprised to learn that Medicare’s coverage for nursing home care is very specific and limited to short-term, medically necessary stays in a skilled nursing facility (SNF). It is not designed to cover long-term custodial care, which is the type of assistance most nursing home residents need. Understanding the distinction between these two types of care is critical for planning purposes.

Custodial vs. Skilled Nursing Care

To grasp Medicare's coverage rules, it's essential to understand the difference between custodial and skilled nursing care. Custodial care is the non-medical assistance with daily living activities (ADLs), such as bathing, dressing, eating, and using the toilet. This type of care, which accounts for the vast majority of long-term nursing home costs, is not covered by Original Medicare if it's the only care required.

In contrast, skilled nursing care is medically necessary care provided by or supervised by licensed professionals, such as registered nurses or physical therapists. This could include services like intravenous injections, wound care, or occupational therapy. Medicare will cover this type of care, but only under strict conditions and for a limited period.

Medicare's Conditions for Skilled Nursing Facility Coverage

For Medicare to cover a stay in a skilled nursing facility, several criteria must be met:

• Qualifying hospital stay: You must have a prior inpatient hospital stay of at least three consecutive days. Time spent under observation or in the emergency room does not count toward this total.
• Timely admission: You must be admitted to the Medicare-certified SNF within 30 days of leaving the hospital for the same or a related condition.
• Doctor's order: A doctor must certify that you need daily skilled care from a licensed professional.
• Benefit period: Coverage is provided for a limited duration per “benefit period,” which begins the day you enter a hospital or SNF and ends when you have gone 60 consecutive days without receiving skilled care.

The 100-Day Skilled Nursing Facility Coverage Limit

Even when all the criteria are met, Medicare's coverage for an SNF stay is limited to 100 days per benefit period. The payment structure is as follows:

• Days 1–20: Medicare covers 100% of the cost, provided the beneficiary has paid their Part A deductible.
• Days 21–100: The beneficiary is responsible for a daily coinsurance payment (in 2025, this amount is $209.50), with Medicare covering the remaining costs.
• Day 101 and beyond: The beneficiary is responsible for all costs.

Other Options for Funding Long-Term Nursing Home Care

Since Medicare's coverage for long-term care is so limited, it is essential to explore other funding options. These alternatives can help cover the high costs associated with extended nursing home stays.

Comparison of Long-Term Care Payment Options	Payment Option	Coverage for Long-Term Care	Eligibility Requirements	Considerations
Original Medicare	Does not cover custodial care; limited coverage (up to 100 days) for skilled care.	Must have Part A and meet specific conditions (e.g., qualifying hospital stay).	Primary benefit is for rehabilitation, not permanent stay; high coinsurance after 20 days.
Medicaid	Comprehensive coverage for long-term custodial and skilled care.	Low income and limited assets; state-specific rules apply.	May require spending down assets to qualify; not all nursing homes accept Medicaid.
Long-Term Care Insurance	Typically covers custodial care in a nursing home or other setting, depending on the policy.	Must purchase a policy and meet health qualifications; can be expensive.	Premiums rise with age; requires careful research of policy terms and waiting periods.
Private Pay	Covers all costs of care in any facility.	Must have sufficient personal funds, investments, or assets.	Can deplete savings quickly; many eventually turn to Medicaid after spending down assets.
Veterans' Benefits	The VA may cover long-term care for eligible veterans.	Requires VA health care enrollment; medical need and service-connected disability status are factors.	Coverage varies based on individual circumstances; eligibility and benefits should be confirmed with the VA.

The Role of Medicare Advantage and Medigap Plans

For individuals with Medicare Advantage (Part C) or Medigap plans, coverage for skilled nursing care may differ slightly from Original Medicare.

Medicare Advantage Plans: These private plans are required to cover everything Original Medicare does but may offer additional benefits. Your specific plan might have different cost-sharing rules for SNF stays, or even waive the 3-day hospital stay requirement. It's crucial to check with your plan provider to understand your specific benefits and costs for SNF care. Some plans also offer supplemental benefits for non-medical services, but this is less common.

Medicare Supplement (Medigap) Plans: Medigap plans help pay for out-of-pocket costs not covered by Original Medicare, including the daily coinsurance for skilled nursing care between days 21 and 100. They do not cover long-term custodial care. If you have Original Medicare and a Medigap plan, you should review your policy to see how much of the SNF coinsurance it covers.

Conclusion

In summary, Medicare does not pay for long-term care in a nursing home. Its coverage is strictly limited to short-term, medically necessary skilled nursing care following a qualifying hospital stay, with a 100-day maximum per benefit period. For most individuals needing extended nursing home care for assistance with daily living activities, Medicare offers no assistance. Consequently, individuals and families must explore other avenues to cover these substantial costs. Proactive planning is essential, and options such as Medicaid, long-term care insurance, veterans' benefits, and personal funds should be considered to ensure financial preparedness for future care needs.

For more information on Medicaid and long-term care, consult your state's Medicaid office or visit the Administration for Community Living website. Administration for Community Living

Frequently Asked Questions

What is the main difference between skilled care and custodial care?

Skilled care is medically necessary care from licensed professionals, such as physical therapy or IV injections. Custodial care is non-medical assistance with daily living activities, like bathing and dressing. Medicare only covers short-term skilled care, not long-term custodial care.

How long does Medicare pay for a skilled nursing facility stay?

Medicare Part A can pay for up to 100 days of skilled nursing care per benefit period. Coverage is full for the first 20 days, followed by a daily coinsurance charge for days 21–100. After day 100, the beneficiary pays all costs.

What is a 'qualifying hospital stay' for Medicare SNF coverage?

A qualifying hospital stay is an inpatient admission of at least three consecutive days, not including the day of discharge. A doctor must order the admission, and observation periods do not count.

Will Medicare cover long-term nursing home care for a dementia patient?

No, Medicare does not cover the costs of long-term nursing home care for a person with dementia. It may cover specific medical services and equipment related to the condition, but not the long-term custodial care provided in the facility.

How can Medicaid help pay for long-term nursing home care?

Medicaid can cover long-term nursing home care, including custodial care, for eligible individuals with low income and limited assets. Eligibility rules are set at the state level.

Does long-term care insurance cover nursing home stays?

Yes, long-term care insurance is a private policy designed to help cover the costs of custodial care in a nursing home or other settings. Coverage depends on the specific policy purchased.

What happens if you have a Medicare Advantage plan?

Medicare Advantage plans are private plans that must cover at least what Original Medicare covers. While they may have different cost structures for SNF stays, they do not generally cover long-term custodial care.