When Will Medicare Pay for a Nursing Home?

Medicare’s coverage for skilled nursing facilities is specific and limited, focusing on recovery and rehabilitation following a hospital stay rather than long-term custodial care. Understanding these guidelines helps clarify when and how Medicare contributes to nursing home expenses. The distinctions are important for individuals and families planning for potential care needs.

Eligibility for Skilled Nursing Facility Coverage

Medicare Part A offers coverage for skilled nursing facility (SNF) care, but specific conditions must be met for eligibility. A primary requirement is a “qualifying hospital stay,” which means an inpatient hospital stay of at least three consecutive days.

Following a qualifying hospital stay, an individual must be admitted to a Medicare-certified skilled nursing facility. Admission to the SNF generally needs to occur within 30 days of leaving the hospital. If an individual leaves the SNF and re-enters within 30 days, a new qualifying hospital stay may not be necessary. The care provided must be for a medical condition treated during the qualifying hospital stay, or a condition that developed while receiving care in the SNF for the original condition.

A doctor’s order is necessary, confirming the need for daily skilled nursing care or skilled therapy services. These services must be delivered by, or under the direct supervision of, skilled nursing or therapy staff. Examples of skilled care include intravenous injections, complex wound care, or physical and occupational therapy. These services must be medically necessary and of a complexity that requires professional personnel.

Skilled care contrasts with general assistance, focusing on medical necessity and professional expertise. For instance, skilled therapy services are considered daily if they are needed and provided five to seven days a week. The care provided in the SNF must be something that can only be safely and effectively administered in an inpatient setting. Daily documentation supports the ongoing need for this clinical skilled care for Medicare coverage to continue.

Covered Services and Patient Financial Responsibility

Once an individual meets the eligibility criteria for Medicare-covered skilled nursing facility care, Medicare Part A covers a range of services. These include a semi-private room, meals, and necessary skilled nursing care provided by licensed professionals. Physical, occupational, and speech-language pathology services are also covered when needed to improve or restore function.

Additional covered services include medical social services, medications, and medical supplies and equipment used within the facility. Ambulance transportation is covered if it is medically necessary to transport the patient to the nearest provider for services not available at the SNF. Dietary counseling is also part of the covered benefits.

Medicare’s coverage for SNF care operates within specific benefit periods. 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 60 consecutive days pass without the individual receiving inpatient hospital or skilled nursing facility care. There is no limit to the number of benefit periods an individual can have.

For the first 20 days of a Medicare-covered SNF stay within a benefit period, Medicare pays 100% of the approved costs, meaning the patient pays nothing. For days 21 through 100, the patient is responsible for a daily co-insurance amount. In 2025, this daily co-insurance is $209.50. After day 100 in a benefit period, Medicare generally does not cover any further costs for skilled nursing facility care, and the patient becomes responsible for all expenses.

Distinguishing Between Covered and Non-Covered Care

Medicare’s coverage for nursing home care specifically targets skilled nursing care, which requires the expertise of qualified health professionals. This type of care is medically necessary and is typically for treating an injury or illness, or for rehabilitation. Examples include specialized wound care, intravenous medication administration, or intensive physical therapy following a stroke.

In contrast, Medicare generally does not cover what is known as custodial care. Custodial care involves non-skilled personal assistance with daily living activities. These activities include bathing, dressing, eating, using the bathroom, and moving around. Such care can be provided safely and effectively by non-medical personnel or caregivers without specialized medical training.

The primary distinction for Medicare coverage is the purpose and level of care required, not merely the setting where care is received. If the main need is for assistance with daily living rather than for skilled medical treatment, Medicare will not pay for the care. This holds true even if the custodial care is provided in a Medicare-certified skilled nursing facility.

Medicare’s policy emphasizes that skilled care must be medically necessary and require professional skills. While some individuals in nursing homes may receive both skilled and custodial services, Medicare coverage is determined by whether the skilled services are the primary reason for the daily need. Medicare does not cover long-term residential stays that are primarily for general assistance or supervision.