What Happens After 100 Days of Medicare?

Medicare provides temporary financial support for skilled nursing facility (SNF) care, specifically for short-term needs after a hospital stay. Understanding the limitations of this coverage, particularly the 100-day period, is important for individuals and families navigating post-hospital care.

Medicare Part A Skilled Nursing Facility Coverage

Medicare Part A, known as Hospital Insurance, covers skilled nursing facility care under specific conditions. To qualify, an individual must have Medicare Part A and days remaining in their benefit period. The care must follow a qualifying inpatient hospital stay of at least three consecutive days, not including the day of discharge. Time spent under observation status or in the emergency room does not count toward this three-day requirement.

Following the qualifying hospital stay, the individual must be admitted to a Medicare-certified SNF within 30 days of hospital discharge. A physician or other healthcare provider must determine that daily skilled nursing or therapy services are necessary. These services must be complex enough to require professional personnel, such as registered nurses or therapists. Skilled care aims to improve, maintain, or prevent a patient’s condition from worsening.

Medicare Part A’s SNF benefit period covers up to 100 days of care. For the first 20 days, Medicare pays the full cost. From day 21 through day 100, a daily co-insurance of $209.50 applies in 2025. Medicare Part A coverage ends once 100 days are used within a benefit period, or if daily skilled care is no longer required. A new benefit period, also covering up to 100 days, can begin if the individual has been out of a SNF or hospital for at least 60 consecutive days and again meets the qualifying hospital stay and skilled care requirements.

Costs After Medicare Part A SNF Coverage Ends

Financial responsibility for skilled nursing facility care shifts significantly once Medicare Part A coverage is exhausted. After day 100 in a benefit period, Medicare Part A no longer covers SNF costs. The patient becomes 100% responsible for all charges from day 101 onwards.

Average daily costs for a skilled nursing facility vary by location and room type. In 2025, the median national cost for a semi-private room is approximately $314 per day, and a private room averages $361 per day. Annually, these costs can accumulate to about $114,665 for a semi-private room and $131,583 for a private room.

Medicare’s coverage for skilled nursing care is for short-term, medically necessary services, not long-term custodial care. If a patient no longer requires daily skilled services, Medicare coverage can cease, even if they have not used all 100 days. This means individuals may become responsible for the full cost if their needs transition from skilled care to custodial care, which involves assistance with daily activities like bathing or dressing.

Paying for Long-Term Care Beyond Medicare

When Medicare Part A SNF benefits conclude, individuals often explore alternative funding for long-term care. Medicaid is a common option for those with limited income and assets. To qualify, applicants must meet strict financial requirements, including asset limits. In most states, the individual asset limit for Medicaid long-term care is approximately $2,000 in 2025.

Medicaid employs a “look-back period,” which examines financial transactions, such as asset transfers, for a specific duration before the application date. In most states, this look-back period is 60 months, or five years. If assets were transferred for less than fair market value during this period, a penalty period of ineligibility for Medicaid coverage may be imposed. This measure helps ensure individuals do not divest assets simply to qualify for Medicaid.

Private long-term care insurance policies offer another way to cover extended care costs. These policies cover services not typically paid by health insurance or Medicare, including nursing home, assisted living, and in-home care. Policies generally pay a daily benefit once conditions are met, such as needing assistance with daily living activities or having cognitive impairment. Most policies include an “elimination period,” often 30 to 90 days, where the policyholder pays out-of-pocket before benefits begin. Benefits are typically capped by a daily limit and a lifetime maximum.

Personal funds, including savings, investments, and home equity, are also frequently used to cover long-term care expenses. Individuals may draw down their liquid assets or consider strategies like reverse mortgages or selling property to fund care. Utilizing personal funds provides flexibility and immediate access to care. However, this approach can rapidly deplete an individual’s accumulated wealth, emphasizing the importance of comprehensive financial planning for potential long-term care needs.

Understanding and Exercising Your Rights

Individuals receiving skilled nursing facility care under Medicare have specific rights regarding coverage decisions and discharge planning. If a Medicare coverage decision is disputed, such as a denial of continued SNF care or a planned discharge, beneficiaries have the right to appeal. Different levels of appeal exist, beginning with an expedited process for situations involving discharge or cessation of services.

To initiate an expedited appeal, the beneficiary or their representative must contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) for their region. This contact typically occurs by noon of the calendar day following receipt of the “Notice of Medicare Provider Non-Coverage.” The SNF must provide this notice at least two days before Medicare coverage ends. The BFCC-QIO reviews the case and determines if skilled services are medically necessary, which may allow Medicare coverage to continue.

If an expedited appeal is unsuccessful or if appealing a standard denial, individuals can pursue further levels of appeal. These include reconsideration by a Qualified Independent Contractor (QIC), a hearing before an Administrative Law Judge (ALJ), review by the Medicare Appeals Council, and judicial review in federal court. Each level has specific timeframes for filing and decisions. For example, an appeal to the QIC usually needs to be filed within 120 days of receiving the initial denial notice.

For assistance with understanding Medicare rights or navigating the appeals process, beneficiaries can contact the Medicare Beneficiary Ombudsman. The Ombudsman helps process complaints and information requests related to Medicare. State Health Insurance Assistance Programs (SHIPs) also offer free, personalized health insurance counseling to Medicare beneficiaries, providing guidance on appeals and other Medicare-related concerns.