What Happens When Medicare Stops Paying for Nursing Home Care?

Medicare often provides initial coverage for skilled nursing facility (SNF) care, but this support is not indefinite. Medicare covers short-term, medically necessary skilled care following a qualifying event, not long-term custodial care. This article explores Medicare SNF benefits, financial responsibilities when coverage ends, and alternative funding options for continued care.

Understanding Medicare’s Nursing Home Coverage

Medicare Part A (Hospital Insurance) covers skilled nursing facility care under specific circumstances. For coverage to initiate, an individual must have a qualifying inpatient hospital stay of at least three consecutive days, not including the day of discharge. This inpatient stay must precede admission to a Medicare-certified SNF, generally within 30 days of hospital discharge.

SNF care must be for a medical condition that required a qualifying hospital stay or a new condition that developed during SNF care. Services must be medically necessary daily skilled nursing or rehabilitation services, such as physical therapy, occupational therapy, or speech-language pathology. These skilled services must be complex enough to require professional personnel. Medicare does not cover non-medical long-term care, including assistance with daily activities like bathing or dressing.

Medicare Part A covers up to 100 days of SNF care per benefit period. A benefit period begins the day an individual is admitted as an inpatient to a hospital or SNF and ends when they have been out of a hospital or SNF for 60 consecutive days. For the first 20 days of a Medicare-covered SNF stay, Medicare pays the full cost, and the beneficiary owes nothing.

For days 21 through 100 in a benefit period, the beneficiary is responsible for a daily coinsurance amount. For 2025, this coinsurance is $209.50 per day. After day 100, Medicare coverage for that benefit period ends, and the individual becomes responsible for all costs. Coverage can also cease before 100 days if the patient no longer requires daily skilled care, stops making progress in rehabilitation, or refuses to participate.

Financial Responsibilities After Medicare Coverage Ends

Once Medicare SNF coverage concludes, the financial burden of nursing home care shifts to the individual and their family. Medicare does not cover long-term custodial care, which is the ongoing care most people associate with nursing homes. After the limited Medicare benefit period, all expenses for room, board, and continued care become the patient’s responsibility.

The costs associated with nursing home care are substantial. As of 2025, the national median cost for a semi-private room in a nursing home is approximately $9,555 per month, or about $314 per day. A private room generally costs more, with a national median of around $10,965 per month, or $361 per day. Annually, these costs can range from roughly $114,665 for a semi-private room to $131,583 for a private room.

This financial responsibility necessitates “private pay,” meaning individuals use personal resources to cover expenses. These resources can include savings, investments, and pensions. Without other assistance, these significant daily and monthly costs can quickly deplete savings. Exploring alternative funding sources is important for managing long-term care needs.

Alternative Payment Options for Long-Term Care

When Medicare coverage for skilled nursing facility care ends, several other options may help cover the ongoing costs of long-term care. These options include government programs like Medicaid, private insurance like long-term care insurance, and certain veterans’ benefits. Each has specific eligibility criteria.

Medicaid

Medicaid is a joint federal and state program providing health coverage to eligible low-income individuals and families. It is a needs-based program, with eligibility determined by income and asset limits that vary by state. For long-term nursing home care, Medicaid can cover the full cost for eligible individuals, often without a time limit, as long as medical necessity and financial criteria are met.

If an applicant’s income or assets exceed limits, they may “spend down” resources to become eligible. This involves using excess funds for approved expenses, such as paying down debt or making home modifications, before applying. A “look-back period,” typically 60 months (five years) in most states, scrutinizes financial transfers to ensure assets were not improperly given away to qualify.

Long-Term Care Insurance

Long-term care insurance is a private policy designed to cover services not typically covered by health insurance, Medicare, or Medicaid. These policies help pay for assistance with routine daily activities, such as bathing or dressing, whether care is provided in a nursing home, assisted living facility, or at home.

When purchasing a policy, individuals choose the amount of coverage, including daily benefit amounts, the length of the benefit period (e.g., three or five years), and an elimination period (a waiting period, typically 30 to 90 days, during which the policyholder pays out-of-pocket). Premiums vary based on age, health, and chosen benefit levels, and can be expensive, potentially increasing over time.

Veterans’ Benefits

Veterans and their surviving spouses may also be eligible for specific benefits that help with long-term care costs. The Department of Veterans Affairs (VA) offers the Aid and Attendance benefit, a monthly pension designed to help cover long-term care services.

To qualify, a veteran must meet service requirements, income and asset limitations, and require assistance with daily activities or be housebound. In 2025, maximum monthly benefits can range from approximately $1,515 for a surviving spouse to $2,358 for a single veteran, or higher for married veterans needing care. This tax-free benefit can be used for care in a private-pay nursing home, assisted living facility, or for in-home care.

Appealing Medicare Decisions

When Medicare decides to terminate coverage for skilled nursing facility care, individuals have the right to appeal this decision. The appeal process allows beneficiaries to challenge a termination of benefits. The nursing facility must provide a written “Notice of Medicare Non-Coverage” at least two days before Medicare coverage is scheduled to end. This notice explains the facility’s reason for termination and outlines the beneficiary’s appeal rights.

An expedited appeal, also known as an immediate advocacy review, can be requested if a beneficiary believes their care is ending too soon. This request must be made by noon of the day after receiving the notice of non-coverage, allowing for a rapid review by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The BFCC-QIO is an independent organization that reviews care’s medical necessity. If the QIO sides with the beneficiary, Medicare coverage will continue.

If the expedited appeal is denied, or if the beneficiary misses the deadline, several subsequent levels of appeal are available. The first step after an expedited appeal denial is a reconsideration by a Qualified Independent Contractor (QIC). If the QIC also denies the appeal, the case can then be escalated to an Administrative Law Judge (ALJ) hearing.

Further appeals can be made to the Medicare Appeals Council and, finally, to judicial review in federal court. Provide all relevant medical documentation supporting the continued need for skilled care. The appeal process focuses on whether the care meets Medicare’s criteria for skilled services, not on the individual’s ability to pay or the availability of alternative care settings.