Does Medicare Pay for Nursing Homes in Texas?

Medicare’s role in covering nursing home care can be complex. Many individuals mistakenly believe Medicare provides comprehensive coverage for all types of long-term care, but this is not the case. The program’s benefits for nursing homes are quite specific and primarily focus on short-term, medically necessary skilled care.

Medicare’s Coverage for Skilled Nursing Facilities

Medicare Part A, which is hospital insurance, covers specific services provided in a Skilled Nursing Facility (SNF). A SNF is a facility equipped with staff and resources to deliver skilled nursing care and rehabilitative services. Medicare’s coverage for SNFs is designed for short-term, medically necessary care rather than long-term custodial support.

Coverage applies when an individual requires daily skilled nursing care or skilled rehabilitation services. Examples of covered skilled services include intravenous injections, complex wound care, physical therapy, occupational therapy, and speech-language pathology services. These services must be so intricate that they can only be safely and effectively performed by, or under the supervision of, licensed medical professionals. Medicare also covers a semi-private room, meals, medications, medical supplies, and ambulance transportation if other transport endangers health.

Conditions for Medicare Skilled Nursing Facility Coverage

To qualify for Medicare coverage of a Skilled Nursing Facility stay, several precise conditions must be met. A primary requirement is a qualifying inpatient hospital stay of at least three consecutive days. This period begins on the day of inpatient admission but does not include the day of discharge, and time spent under observation status or in the emergency room before admission does not count towards this three-day minimum.

After the qualifying hospital stay, the individual must be admitted to a Medicare-certified SNF typically within 30 days of hospital discharge. A physician must certify that daily skilled nursing care or therapy is medically necessary for a condition that was treated during the qualifying hospital stay or arose while receiving care in the SNF for that condition. The care provided must aim to improve the patient’s condition, maintain their current function to prevent decline, or slow the progression of a condition from worsening.

Limits on Medicare Skilled Nursing Facility Coverage

Medicare’s coverage for Skilled Nursing Facility care comes with specific financial and temporal limits. Coverage is measured within “benefit periods,” where a new period begins the day an individual is admitted as an inpatient in a hospital or SNF. This benefit period concludes when the individual has not received inpatient hospital care or skilled care in a SNF for 60 consecutive days.

Within each benefit period, Medicare Part A covers up to 100 days of skilled nursing facility care. For the first 20 days of a covered SNF stay, Medicare pays 100% of the costs. From day 21 through day 100 of the benefit period, a daily co-insurance amount applies, which is $209.50 per day in 2025. After the 100-day limit within a benefit period is reached, the beneficiary becomes responsible for all costs. Coverage also terminates if skilled care is no longer deemed medically necessary, even if the 100-day limit has not been exhausted.

Understanding Custodial Care and Alternative Payment Options

Medicare does not cover custodial care, which involves assistance with Activities of Daily Living (ADLs) such as bathing, dressing, eating, or using the toilet. This type of care is non-medical and can be provided by non-licensed caregivers, unlike the skilled care that Medicare covers. Most long-term nursing home stays primarily involve custodial care.

Medicaid is a significant option for covering long-term nursing home care, including custodial care, for individuals with limited income and assets.

Medicaid Eligibility in Texas (2025)

In Texas, for 2025, a single applicant for nursing home Medicaid generally must have a monthly income no greater than $2,901 and countable assets under $2,000. For married couples where both apply, the income limit is $5,802 per month, with countable assets up to $3,000. If only one spouse applies, the applicant’s income limit remains $2,901, and the non-applicant spouse can retain a greater share of assets, up to $157,920 in 2025. Certain assets, such as a primary residence with equity up to $730,000 or $788,000, and one automobile, are often exempt from these limits. Texas also has a five-year look-back period for asset transfers, which can affect eligibility.

Long-term care insurance is a private insurance product designed to cover various long-term care services, including nursing home care, home health care, and adult day care, often encompassing both skilled and custodial care. Another common approach is private pay, where individuals use personal savings, pensions, or liquidate assets to cover the costs.

Veterans and their surviving spouses may also be eligible for the Aid and Attendance benefit, an additional pension provided by the Department of Veterans Affairs. This benefit can help offset the costs of nursing home care for those who require assistance with daily living activities. Eligibility depends on service during wartime, medical need, and financial criteria.