Medicare's Limited Nursing Home Coverage

Many people believe that Medicare covers nursing home stays. In fact, Medicare's coverage of nursing home care is quite limited.

Medicare covers up to 100 days of skilled nursing care per illness, but there are a number of requirements that must be met before the nursing home stay will be covered.

The result of these requirements is that Medicare recipients are often discharged from a nursing home before they are ready.

When a Nursing Home Stay Is Covered by Medicare

In order for a nursing home stay to be covered by Medicare, you have to meet the following requirements:

• You must enter the nursing home no more than 30 days after a hospital stay (admission as an inpatient under observation status doesn't count) that lasted for at least three days (not counting the day of discharge).
• The care you receive in the nursing home must be for the same condition that caused your hospitalization (or a condition medically related to it).
• You must receive a "skilled" level of care in the nursing facility that can't be provided at home or on an outpatient basis. In order to be considered skilled, nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse, or licensed practical nurse. In addition, care must be delivered daily. (Few nursing home residents receive this level of care.)
• Medicare only covers "acute" care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not for people who need ongoing help with performing everyday activities, such as bathing or dressing. Many nursing homes assume in error that if a patient has stopped making progress toward recovery, then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain their status (or to slow deterioration), then the care should be provided and is covered by Medicare.

If You Need Skilled Nursing Care

Note that if you need skilled nursing care to maintain your status (or to slow deterioration), then the care should be provided and covered by Medicare.

In addition, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but which may, in combination, require skilled supervision. For example, the potential for adverse interactions among multiple treatments may require that a skilled nurse monitor the patient's care and status. In these cases, Medicare should continue to provide coverage.

Written Notice

When you leave a hospital and move to a nursing home that provides Medicare coverage, the nursing home must give you written notice of whether the nursing home believes that you require a skilled level of care and merit Medicare coverage.

Once you are in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies.

Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($194.50 a day in 2023). This copayment may be covered by a Medigap (supplemental) policy. After 100 days are up, you are responsible for all costs.

If you are in a nursing home and the nursing home believes that Medicare will no longer cover you, it must give you a written notice of noncoverage. The nursing home cannot discharge you until the day after the notice is given.

The notice should explain how to file an expedited appeal to a Quality Improvement Organization (QIO). A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries. You should appeal right away. You will not be charged while waiting for the decision, but if the QIO denies coverage, you will be responsible for the cost. If the QIO denies coverage, you can appeal the decision to an Administrative Law Judge (ALJ). It is recommended that a patient hire a lawyer to pursue an appeal. Check out an article from the Center for Medicare Advocacy on nursing home discharges.

You can't rely on Medicare to pay for your long-term care. Contact an attorney near you to create a long-term care plan.

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