Does Medicare Cover Nursing Homes?

Medicare Benefits Solutions

Aug 24, 2020

Aging is unavoidable, and sometimes, it becomes more difficult to live independently. Whether due to impaired physical mobility, cognitive functions, illness or injury, there are many scenarios that leave Medicare beneficiaries unable to live alone. When family members are unable to provide the care a loved one needs, a nursing home may the right solution. These facilities can provide support, safety, comfort, and assistance in activities of daily living. However, these facilities can also be expensive, which may lead you to wonder if Medicare can help.  

Care terminology

When you begin to look into care facilities and the coverage that Medicare benefits provide, it is important to understand the difference between these two terms:

Custodial care

Custodial care is defined as personal care that is given to individuals to help them with normal activities of daily living. These activities can include bathing, dressing, eating, standing or sitting in a chair, moving from location to location, and more. This is considered non-medical care.  

Skilled nursing facility care

A skilled nursing facility includes care given by medical professionals, including nurses, physicians, or therapists.

If you have Original Medicare, coverage will only be offered for skilled nursing care. Medicare Advantage plans may include additional benefits beyond Part A and Part B coverage. used to provide coverage the same way.

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Skilled nursing facility care

Medicare provides coverage for care that is deemed “medically necessary.” With Original Medicare, coverage depends on whether the patient is unable to leave their home without assistance and if care is required and prescribed by a doctor. Medicare Advantage plans may offer additional benefits.

In most long-term care facilities, including nursing homes, the majority, if not all, care that is provided is not medically necessary. These facilities often are not covered by Medicare, and because of this, the out-of-pocket costs can be extremely high. 

Medicare does provide coverage for skilled nursing facilities. If you or your loved one must stay in a skilled nursing facility, both Original Medicare and Medicare Advantage will provide coverage for the stay. However, there are a few conditions that must be met in order for coverage to apply. 

First, the care being provided must aid in the healing process from an illness or injury, and this condition cannot be chronic. Additionally, the person must also have stayed in the hospital for at least three days prior to admission to the facility. If these conditions are met, the first 20 days in the skilled nursing facility will be covered 100 percent, the next 80 days will be covered 80 percent, and then each day over 100 will not be covered at all.

Additional financial assistance

If a nursing home stay is required for you or a family member, there are alternative options for funding if your Medicare benefits do not provide adequate coverage. For lower-income individuals, Medicaid provides coverage for a variety of long-term care needs. Various non-profit foundations and the Veteran’s Administration can provide additional resources as well.

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