What Happens When Medicare Stops Paying for Nursing Home Care?

After a hospital stay, your loved one might be transferred to a skilled nursing facility (SNF), often called a nursing home, for rehabilitation. Medicare may cover the initial costs, but many families are surprised and stressed when they receive a notice that this coverage is about to end.

Facing the question of how to pay for continued care can be daunting. This guide explains why Medicare's nursing home coverage is limited, what happens when it stops, and what your options are for covering the cost of long-term care.

Understanding Medicare’s Limited Nursing Home Coverage

It's crucial to understand that Medicare is not designed for long-term care. It primarily covers short-term, medically necessary care in a Skilled Nursing Facility (SNF) following a hospital stay. This is different from long-term custodial care—help with daily activities like bathing, dressing, and eating—which Medicare generally does not cover if it's the only care you need.

Key Requirements for Medicare SNF Coverage:

• Medicare Part A: Coverage falls under Medicare Part A (Hospital Insurance).
• Qualifying Hospital Stay: You must have a prior inpatient hospital stay of at least three consecutive days.
• Skilled Care Needed: Your doctor must certify that you need daily skilled care, such as physical therapy, wound care, or intravenous injections, that can only be provided by skilled medical personnel.

Duration and Cost of Medicare Coverage

Medicare's SNF coverage is capped at a maximum of 100 days per benefit period. A benefit period begins when you're admitted to a hospital or SNF and ends when you haven't received any inpatient care for 60 days in a row.

Here is how the cost-sharing works for each benefit period (based on 2024 figures):

Days in SNF Care	Medicare Coverage	You Pay (2024)
Days 1–20	Full coverage of approved costs	$0 per day
Days 21–100	Covers all but a daily coinsurance	$204 per day
Days 101+	No coverage	All costs

A Medigap (Medicare Supplement Insurance) policy may cover the daily coinsurance for days 21–100. However, after day 100, you are responsible for all costs.

Why Medicare Stops Paying for Nursing Home Care

Medicare coverage for SNF care can end for two main reasons:

1. You’ve Reached the 100-Day Limit: Coverage automatically ends on day 101 of a continuous stay within a single benefit period.
2. You No Longer Need Skilled Care: Medicare may stop paying before day 100 if it's determined that you no longer require daily skilled nursing or therapy services, even if you still need custodial care.

Before coverage ends, you must receive a written notice called the “Notice of Medicare Non-Coverage” (NOMNC). This document will state the date your coverage ends and explain your right to a fast appeal if you disagree with the decision. You can request an expedited review from your state's Quality Improvement Organization (QIO).

What to Expect When Medicare Coverage Ends

When Medicare stops paying, it does not mean you must leave the facility immediately. It means the financial responsibility for care shifts to another source.

• Discharge Planning: The nursing home’s care team will meet with you to discuss the next steps.
• Going Home: If you are well enough, a plan will be created for a safe discharge home. This may include arranging for outpatient therapy or Medicare-covered home health care if you qualify.
• Staying in the Facility: If you still need nursing home care, you must arrange for another way to pay. The facility will begin billing you or another payer directly. The cost of nursing home care is substantial, with the national median cost for a semi-private room being over $8,000 per month, according to the Genworth Cost of Care Survey.

How to Pay for Nursing Home Care After Medicare

When Medicare coverage runs out, families typically turn to one or more of the following options.

1. Private Pay (Out-of-Pocket)

This involves using personal funds to cover the costs.

• Sources: Savings, pensions, Social Security benefits, retirement accounts, or the sale of assets like a home.
• Long-Term Care Insurance: If you have a long-term care insurance policy, this is the time to activate it. These policies are specifically designed to cover costs that Medicare does not, including custodial care in a nursing home. Contact the insurance provider to understand the benefits and start a claim.

2. Medicaid

Medicaid is a joint federal and state program that serves as a crucial safety net for long-term care. It is the largest single payer of nursing home bills in America.

• Eligibility: Medicaid is for individuals with limited income and assets. To qualify, a person may need to "spend down" their assets by paying for their care out-of-pocket until they meet their state's low asset threshold (often around $2,000 for an individual).
• Spousal Protections: If one spouse needs nursing home care, "spousal impoverishment" rules allow the healthy spouse at home to keep a certain amount of income and assets.
• Application: The application process is complex and requires extensive financial documentation, often including a review of the past five years of finances (the "look-back period"). It is wise to start the application process well before Medicare coverage ends. The facility's social worker can often provide assistance.

3. Other Potential Sources

• Veterans (VA) Benefits: Eligible veterans may receive long-term care benefits through the VA. This can include care in VA nursing homes or financial assistance through programs like the Aid and Attendance benefit. For more information, visit the VA's Geriatrics and Extended Care page.
• Medicare Advantage (MA) Plans: While MA plans must cover the same SNF benefits as Original Medicare, some may offer slightly different rules or supplemental benefits. However, they do not cover long-term custodial care. Check your plan's Evidence of Coverage document for details.
• PACE: The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare/Medicaid program available in some states that helps people meet their healthcare needs in the community instead of a nursing home. Learn more at Medicare.gov's PACE page.

A Step-by-Step Guide to Prepare

Being proactive can make the transition smoother.

1. Communicate Early: Talk to the nursing home's social worker or case manager regularly to project when Medicare coverage might end.
2. Assess Care Needs: Discuss with the medical team whether a return home with support is feasible or if long-term facility care is necessary.
3. Evaluate Finances: Take stock of all available financial resources to determine how long you can pay privately, if at all.
4. Start Medicaid Planning: If Medicaid seems likely, begin gathering financial documents immediately.
5. Consult Professionals: An elder law attorney or a financial planner specializing in senior care can provide invaluable guidance on asset protection and Medicaid eligibility.
6. Consider Alternatives: Explore other care settings like assisted living or in-home care, which may be less expensive than a nursing home.
7. Know Your Rights: A facility cannot discharge a resident without a safe and orderly plan. If you face issues, contact your state's Long-Term Care Ombudsman Program, which advocates for residents' rights.

The Common Transition: From Medicare to Medicaid

For many, the path involves using Medicare for short-term rehabilitation and then transitioning to Medicaid for long-term care.

To be approved for Medicaid long-term care, an individual must meet both financial criteria (low income/assets) and level-of-care criteria (a documented medical need for nursing home care).

While a Medicaid application is pending, it is important to communicate with the nursing home's billing office. Many facilities will allow a resident to remain while awaiting a decision, especially if approval is likely. Once approved, Medicaid can sometimes provide retroactive coverage for a period after Medicare ended. The resident will then contribute most of their monthly income (like Social Security) toward their care, and Medicaid will pay the remaining amount.

Helpful Resources

• Medicare.gov - Skilled Nursing Facility (SNF) Care: The official source for Medicare's SNF coverage rules.
• Medicare & You Handbook: This official government guide provides comprehensive information on all parts of Medicare.
• Your State's Medicaid Agency: Find information about eligibility and how to apply for long-term care benefits.
• AARP - Paying for Nursing Home Care: AARP provides a helpful overview of the various financial and legal aspects of caregiving.
• Eldercare Locator: A public service of the U.S. Administration on Aging connecting you to services for older adults and their families. Visit the Eldercare Locator website.
• State Health Insurance Assistance Program (SHIP): SHIPs provide free, unbiased counseling on Medicare and Medicaid. Find your local SHIP at www.shiphelp.org.

Frequently Asked Questions (FAQ)

How long will Medicare pay for nursing home care?

Medicare Part A will pay for up to 100 days in a skilled nursing facility (SNF) per benefit period, provided you meet the criteria (e.g., a qualifying hospital stay and a need for daily skilled care). For days 1–20, Medicare covers 100% of approved costs. From days 21–100, you pay a daily coinsurance ($204 per day in 2024). After 100 days in a benefit period, Medicare coverage stops.

Why does Medicare stop paying after 100 days?

Medicare’s skilled nursing facility benefit is designed for short-term rehabilitation, not long-term custodial care. The 100-day limit is set by law. Medicare may also stop paying before 100 days if it's determined that you no longer require daily skilled care, even if you still need help with daily activities (custodial care).

What’s the difference between Medicare and Medicaid for nursing home coverage?

Medicare provides short-term skilled nursing facility (SNF) coverage for rehabilitation after a hospital stay, limited to 100 days. It does not cover long-term custodial care. Medicaid is a needs-based program for individuals with limited income and assets; it is the primary payer for long-term custodial nursing home care and can cover stays indefinitely as long as you qualify.

Can a nursing home evict someone once Medicare stops paying?

A nursing home cannot immediately evict a resident when Medicare stops paying. Federal law requires proper procedure, including a 30-day written notice and a safe discharge plan. If you are applying for Medicaid or arranging other payment, communicate this to the facility. If you feel a discharge is unsafe or improper, contact your state’s Long-Term Care Ombudsman.

What should we do if we can’t afford to pay for the nursing home out-of-pocket after Medicare stops?

If you cannot afford to pay privately, you should apply for Medicaid as soon as possible. Medicaid is the primary program designed to cover long-term nursing home costs for those who are financially eligible. You can also explore other options like veterans benefits or long-term care insurance if applicable. Speak with the facility's social worker for guidance on the Medicaid application process.

Will a Medicare Supplement (Medigap) or Medicare Advantage plan cover additional nursing home days?

No. Medigap plans help cover Medicare's out-of-pocket costs (like the daily coinsurance) but do not extend coverage beyond the 100-day limit. Medicare Advantage plans must provide at least the same level of coverage as Original Medicare and generally do not cover long-term nursing home stays beyond the short-term skilled care period.

Can I get another 100 days of Medicare nursing home coverage by returning to the hospital?

A new 100-day benefit period can start only after you have been out of a hospital or skilled nursing facility for 60 consecutive days. If you then have a new qualifying 3-day hospital stay, you may be eligible for a new SNF benefit period. You cannot restart coverage while continuously residing in the facility.

Does Medicare cover any in-home care if I leave the nursing home?

Yes, Medicare can cover part-time, medically necessary home health care if a doctor certifies you are homebound and need skilled nursing or therapy services. This benefit covers services like skilled nursing visits and physical therapy, but it does not cover 24/7 care or long-term custodial care at home.

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Disclaimer: This article provides general information and should not be considered legal, financial, or medical advice. Consult with qualified professionals for guidance tailored to your specific situation.