When the time comes to transition to nursing home care, figuring out how to pay for it is often a primary concern.
Does Medicare Cover Nursing Homes?
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No, Medicare does not pay for long-term nursing home care, also referred to as custodial care.
While Medicare Part A (hospital insurance) is designed to pay for short-term medical needs, such as hospital stays and skilled nursing care following a hospital discharge, it does not cover ongoing nonmedical assistance of custodial care that helps individuals with activities of daily living.
What is custodial care?
Custodial care focuses on providing support for basic personal tasks rather than addressing specific medical conditions or treatments that are covered under skilled medical care.
Key features of custodial care include:
— Basic household chores like cleaning
— Bathing and grooming
— Dressing
— Eating
— Meal planning
— Mobility, such as transferring from bed to chair
— Toileting
[READ What to Do When Medicare Stops Paying for Skilled Nursing Care]
What Does Medicare Cover?
If you need a nursing home for a short-term stay, Medicare pays for the short-term care and rehabilitation needed to treat and manage your condition for up to 100 days.
It covers the following services:
— Ambulance transportation
— A semi-private room
— Dietary counseling
— Meals
— Medical supplies and equipment
— Medical social services, including counseling
— Occupational therapy
— Skilled nursing care
If you are in a nursing home for a long-term stay, Medicare may provide some benefits related to your health care needs. Depending on your situation your plan may cover:
— Doctor and specialist visits
— Durable medical equipment, such as wheelchairs or walkers
— Prescription medications
— Preventive services, such as vaccinations or screenings
— Therapeutic services, such as physical, occupational, speech and cognitive therapy
“Medicare may cover physical, occupational and speech therapies in a skilled nursing setting if they are part of a prescribed plan of care,” explains Gretchen Jacobson, vice president of the Medicare program for the Commonwealth Fund in New York City. “Therapy must be intended to improve, maintain or slow the decline of a patient’s functional ability due to a medical condition. Cognitive therapy can sometimes be covered if there’s a clear medical justification.”
Always check with your plan to determine what benefits you are entitled to.
Medicare Advantage plans may have further benefits, costs or requirements that you should be aware of before making any decisions, Jacobson explains.
Your doctor or health care provider might recommend services more often than what Medicare typically covers or suggest treatments that Medicare does not include. In these situations, you may have to cover some or all of the costs yourself. It’s important to ask questions to clarify why certain services are being recommended and to understand how much Medicare will cover.
[READ: Tips for Choosing a Good Nursing Home]
Qualifying for Short-Term Care
Medicare Part A provides coverage for short-term skilled nursing home care if you meet certain eligibility criteria. According to Medicare.gov, you must fulfill all of the following requirements to qualify for Medicare Part A coverage:
— You have Part A and also have time left in your benefit period.
— You’ve had a hospital stay of at least three days (not including the day you leave the hospital).
— Your doctor determines you need daily skilled nursing care.
— You require skilled nursing services for a hospital-related medical condition (such as an infection) that was treated during your qualifying three-day inpatient hospital stay, even if it wasn’t the reason for your admission.
— You enter the facility within 30 days of leaving the hospital.
— You need skilled nursing care or therapy to maintain or improve your condition or to prevent or delay the condition from getting worse.
— Your care is in a Medicare-certified skilled nursing facility.
[READ: How to Pay for a Nursing Home With No Money.]
Paying for Care
Your portion of the bill for a short-term stay depends on the length of time you are there and if you have original Medicare or a Medicare Advantage plan.
Under original Medicare the cost breakdown is:
— First 20 days. Patients pay $0 after the deductible.
— Days 21 to 100. Up to $204 per day, depending on how the patient is progressing and what their care needs are over time.
— After day 100. 100% of the cost of care.
Medicare Advantage plans are required to offer at least the same coverage as original Medicare, but they may differ in areas such as costs and facility requirements. For example, some plans may charge a copayment for the first 20 days of care or require the use of in-network facilities to access benefits.
“Medicare Advantage does not have the consistent benefits original Medicare does,” says Colleen Duewel, founder and president of LionHeart Eldercare & Consulting in Falls Church, Virginia. “Be aware that Medicare Advantage plans vary widely, depending on the plan. Many do not require the three-day stay in the hospital, but most don’t pay for 100 days of coverage.”
It’s essential to review your specific plan details to understand your benefits, costs and any applicable requirements before entering a facility.
For custodial care, you are responsible for the bill minus any medical-related expenses that Medicare may cover. Although it depends on factors such as where you live and what level of care you need, the median cost of a nursing home room according to Genworth Financial’s 2023 Cost of Care Survey is $8,669 per month for a semi-private room and $9,733 per month for a private room.
There are other ways to pay for nursing home care, including:
— Long-term care insurance. Long-term care insurance is a type of insurance policy that helps cover the costs of long-term care services such as nursing homes.
— Medicaid. If you do not qualify for Medicaid, there are different ways, including paying out-of-pocket to deplete financial resources or doing a spend down, to get yourself to the financial threshold needed to apply. According to the Centers for Disease Control and Prevention (CDC), Medicaid is the primary payer for 62% of nursing home residents.
— Self-pay. There is always the option of paying out-of-pocket, but that can add up fast. In 2023 according to Genworth Financial, the median annual cost of a semi-private room was $104,025 and a private room was $116,800.
— Veteran’s benefits. Veterans must be enrolled in Veteran’s Administration health care before applying for VA long-term care services. For further details check the VA Geriatrics and Extended Care page.
“Even if Medicaid covers nursing home costs, Medicare remains the primary insurance for medical services like doctor visits, hospital stays and medications,” Duewel says. “Medicaid helps with the long-term care portion (custodial care), while Medicare continues to manage the individual’s medical health.”
Finding Nursing Homes Near You
Your doctor is a good place to start looking for recommendations. Word-of-mouth from friends, family or other members of your community are also helpful resources. Medicare provides a list of Medicare-certified facilities on its website.
Another great resource is U.S. News’s 2025 Best Nursing Homes. Almost 15,000 nursing homes were evaluated and rated in two areas, short-term rehabilitation and long-term care, so you can find the best fit for you or your loved one.
Bottom Line
Medicare pays for short-term care in a nursing home for up to 100 days, but you must fulfill certain requirements to qualify and, depending on your plan, copayments, deductibles and other costs may apply.
Custodial care, meaning nonmedical help with the activities of daily living, is not covered, but certain aspects of care may be such as doctor visits and medications. Check with your plan to find out what is available to you.
Nursing homes can be a significant financial burden, costing an average of $104,025 per year for a semi-private room. There are various options to help cover these costs, including long-term care insurance, out-of-pocket payments, Medicaid and benefits from the VA.
More from U.S. News
Nursing Home Red Flags You Should Watch Out For
How to Pay for a Nursing Home With No Money
How to Choose the Right Senior Living Facility: A Checklist
Does Medicare Pay for Nursing Homes? originally appeared on usnews.com
