What Happens When Medicare Stops Paying for Nursing Home Care?

When Medicare stops covering nursing home or skilled nursing facility (SNF) care, many patients and families wonder what options are available.

This can be a stressful transition, but understanding Medicare’s coverage limitations and exploring alternative funding sources can help ensure continued care for yourself or a loved one.

What Does Medicare Cover for Nursing Home Care?

Medicare covers short-term stays in a skilled nursing facility (SNF) under specific conditions. Here’s a summary of what’s covered:

• Up to 100 Days of Skilled Nursing Care: Medicare Part A covers a limited stay in an SNF after a qualifying hospital stay of at least three days. This includes skilled nursing care, physical therapy, occupational therapy, medications, and other necessary treatments.
• Cost Structure:
  • Days 1-20: Medicare covers the full cost.
  • Days 21-100: Medicare requires a daily copayment (currently $200 in 2024).
  • After 100 Days: Medicare stops covering SNF care entirely.

Important: Medicare only covers SNF care for patients who need skilled medical services on a daily basis. Once a patient no longer needs daily skilled care or reaches the 100-day limit, Medicare coverage ends.

What Are the Options When Medicare Stops Paying for Nursing Home Care?

When Medicare coverage ends, there are several options for funding ongoing care. Here’s a breakdown of common options to consider:

1. Medicaid

Medicaid is a federal and state program that helps cover healthcare costs for individuals with low income. Unlike Medicare, Medicaid can cover long-term nursing home care if you meet eligibility requirements.

• Eligibility: Each state sets specific income and asset limits. In most states, individuals must spend down their assets to qualify for Medicaid.
• Coverage: Medicaid covers long-term care in a nursing home for eligible individuals, with no time limit.

Tip: Consider talking to a Medicaid planner or elder law attorney if you need guidance on Medicaid eligibility.

2. Private Pay (Out-of-Pocket)

If Medicaid is not an option, you may need to pay out-of-pocket for nursing home care.

• Costs: Nursing home costs vary by location but can be substantial, often ranging from $7,000 to $10,000 per month or more.
• Using Personal Assets: Families may need to use personal savings, retirement funds, or other assets to cover costs.

Pro Tip: Some facilities may offer payment plans or sliding scale fees for patients paying privately. Get a Solace advocate to figure this out for you. Our advocates are covered by Medicare.

3. Long-Term Care Insurance

If you have long-term care insurance, it may cover nursing home care once Medicare stops paying.

• Coverage: Long-term care policies typically cover various levels of care, including skilled nursing, assisted living, and home health services.
• Limitations: Policies vary widely, so check the terms to understand what services are covered and for how long.

Important: Long-term care insurance is only effective if you purchase it well before you need it, as it’s challenging to qualify for coverage with pre-existing health conditions.

Get a Solace advocate insurance expert to help you with this.

4. Veterans Benefits

If you or your loved one is a U.S. veteran, you may qualify for additional support through Veterans Affairs (VA) benefits.

• VA Nursing Homes: The VA operates its own nursing home facilities, which provide long-term care for eligible veterans.
• Aid and Attendance Benefit: This benefit offers monthly financial support for qualifying veterans who need help with daily living activities, which can help offset nursing home costs.

How to Plan for Nursing Home Costs After Medicare Ends

It’s wise to explore all available options and plan for nursing home care costs, especially if long-term care is anticipated.

1. Assess Eligibility for Medicaid: If nursing home care is a long-term need, Medicaid may be the most affordable option. Plan to assess eligibility requirements and apply early, as approval can take time.
2. Consider Long-Term Care Insurance: For those who haven’t yet needed nursing home care, long-term care insurance can offer essential protection. Explore policy options to see if this type of insurance might be beneficial. Get an advocate to help you with this.
3. Review Veterans Benefits: Veterans and their spouses may have access to additional financial support, which can help cover long-term care expenses.

Tip: Even if Medicare coverage ends, proactive planning can prevent financial strain and keep quality care accessible.

Planning ahead for long-term care needs

Medicare’s coverage of nursing home care is limited to short-term, skilled nursing needs. When coverage ends, families often need to explore other funding options like Medicaid, private pay, or long-term care insurance to continue care.

Proactive planning can make this transition smoother and help you meet your ongoing care needs. If you have questions about long-term care options or need assistance navigating Medicare and Medicaid, reach out to a Solace advocate for guidance and support.

FAQ: Questions on Nursing Home Care

How long does Medicare cover nursing home care?

Medicare covers up to 100 days in a skilled nursing facility after a qualifying hospital stay, with full coverage for the first 20 days and a daily copayment required for days 21-100.

Does Medicaid cover long-term nursing home care?

Yes, Medicaid can cover long-term care in a nursing home for eligible individuals, without a time limit, as long as they meet income and asset requirements.

What happens if a patient’s health improves?

If the patient no longer needs daily skilled care, Medicare coverage ends. In this case, they may still qualify for custodial care, which is not covered by Medicare, or explore Medicaid if eligible.

Can Medicare patients return to the SNF if they need skilled care again?

Yes, if the patient has a new qualifying hospital stay of at least three days, they may qualify for a new benefit period of up to 100 days of SNF coverage.

What are other payment options after Medicare stops covering nursing home care?

Options include Medicaid, private pay, long-term care insurance, and veterans benefits, depending on eligibility and available resources.