Does Medicare Pay for the First 100 Days in a Nursing Home?

Medicare provides healthcare coverage, particularly for older individuals. Understanding its scope, especially for nursing home care, is important. Medicare primarily covers skilled nursing facility care under specific conditions, not broad long-term residential or custodial care. This distinction is fundamental to how Medicare benefits apply in a nursing home setting.

Medicare Part A Coverage for Skilled Nursing Facility Care

Medicare Part A covers skilled nursing facility (SNF) care when certain conditions are met, focusing on recovery from illness or injury. SNF care involves daily services provided by, or under the supervision of, trained medical professionals like registered nurses or licensed therapists. These services include medical treatments and rehabilitative therapies. The care must be medically necessary, meaning a physician has ordered daily skilled services requiring professional oversight.

A prerequisite for Medicare Part A coverage of SNF care is a qualifying inpatient hospital stay. This requires hospital admission as an inpatient for at least three consecutive days, not including the day of discharge. Time spent under observation status, even overnight or in the emergency room, does not count toward this three-day inpatient requirement.

Hospitals are generally required to notify patients if they are under observation status, as this can impact subsequent Medicare coverage for SNF care. Only a formal inpatient admission, documented by a physician’s order, fulfills Medicare’s requirement for a qualifying hospital stay. The care provided in the SNF must be for a condition treated during the qualifying hospital stay or one that developed while receiving SNF care for the original condition.

The skilled nursing facility must be certified by Medicare for coverage to apply. The necessity of daily skilled nursing or rehabilitative services is continuously assessed, and these services must be complex enough to require professional personnel. The objective of skilled care does not solely need to be improvement; maintaining a patient’s condition or preventing further decline can also qualify for coverage.

The 100-Day Coverage Limit and Cost-Sharing

Medicare Part A coverage for skilled nursing facility stays is limited to a maximum of 100 days within each benefit period. A benefit period begins the day an individual is admitted as an inpatient to a hospital or a skilled nursing facility. This period ends when the individual has not received any inpatient hospital care or skilled care in an SNF for 60 consecutive days.

For the initial 20 days of a Medicare-covered skilled nursing facility stay within a benefit period, the beneficiary pays no co-insurance. Medicare covers the full cost during this period. This supports short-term recovery and rehabilitation needs.

From day 21 through day 100 of the skilled nursing facility stay within the same benefit period, the beneficiary is responsible for a daily co-insurance payment. For 2025, this daily co-insurance amount is $209.50. After day 100 in a benefit period, Medicare ceases to cover skilled nursing facility costs, and the beneficiary becomes responsible for the full cost of care. Continued coverage, even within the 100 days, remains contingent on the patient’s ongoing need for daily skilled nursing or rehabilitative services.

Services Not Covered by Medicare in Nursing Homes

Medicare does not cover all types of care in a nursing home setting, particularly long-term custodial care. Custodial care refers to non-skilled assistance with activities of daily living (ADLs), including personal care such as bathing, dressing, eating, using the restroom, or moving around.

Services that primarily involve assistance with routine personal needs, rather than skilled medical intervention, fall under the category of custodial care. Examples include help with getting in and out of bed, feeding, or supervision for safety reasons when no skilled medical services are required. If a patient’s needs are solely for these types of services, Medicare will not cover the nursing home stay.

The distinction is based on the nature of the care required, not the location where it is provided. While a nursing home may provide both skilled and custodial care, Medicare coverage is limited strictly to the skilled component, and only for a defined period. This means that once the need for daily skilled nursing or rehabilitative services ends, Medicare coverage for the nursing home stay will cease, even if the individual still requires assistance with daily activities.

Starting Medicare Coverage for Skilled Nursing Facility Stays

To start Medicare coverage for a skilled nursing facility (SNF) stay, several conditions must be met. Confirming the patient’s hospital admission status is a primary consideration; it must be a formal inpatient admission for at least three consecutive days, not observation status. This inpatient designation triggers Medicare Part A’s SNF benefit.

The physician’s certification must state the patient’s need for daily skilled nursing or rehabilitative services following the hospital stay. This order establishes the medical necessity Medicare requires for SNF coverage. The skilled nursing facility selected must also hold Medicare certification, as Medicare only pays for services provided in approved facilities.

Admission to the SNF must occur within 30 days of the patient’s discharge from the qualifying hospital stay. This timeframe ensures a direct link between the hospital treatment and subsequent skilled care needed for recovery. While the SNF handles direct billing to Medicare, the patient or their family should verify that all conditions are met to initiate coverage.