Financial

How Much Does Medicare Pay for Long-Term Nursing Home Care?

Diane Carbo

Sep 15, 2023 — 13 min read

Introduction to Long-Term Nursing Home Care and How it is Covered by Medicare

Long-term nursing home care is a type of medical care provided by a skilled nursing facility for individuals who cannot take care of themselves due to an illness, disability, or other health condition. Nursing homes provide 24-hour care and support with activities of daily living such as eating, bathing, dressing, grooming, toilet use, and medication management. They are typically private pay facilities, which means that out-of-pocket expenses can be quite costly.

Fortunately, Medicare provides some coverage for long-term nursing home care. While the amount of coverage will depend on your individual situation, there are certain eligibility criteria that must be met in order for Medicare to pay for your nursing home expenses. In this guide, we’ll provide an overview of Medicare coverage for long-term nursing home care, as well as help you understand what types of services are covered, how much Medicare pays for nursing home care, and how to make sure your nursing home care is covered by Medicare.

Overview of Medicare Coverage for Long-Term Nursing Home Care

Medicare is a health insurance program managed by the federal government. It is available to people age 65 and older, as well as individuals with certain disabilities. Medicare may pay for the cost of nursing home care under limited circumstances.

In general, Medicare covers short-term nursing home stays for medically necessary skilled care. Long-term nursing home care is also covered, but only under certain circumstances and with specific criteria in place. In order for Medicare to pay for long-term nursing home care, a doctor must certify that the individual needs supportive care and the services must be provided by a Medicare-approved facility.

Medicare coverage for long-term nursing home care consists of two parts: Part A and Part B. Part A is designed to cover the costs associated with hospital stays, while Part B covers medical services and supplies (such as doctor visits). To qualify for Part A coverage, an individual must meet certain financial criteria (i.e., deductible payments must be met before Medicare begins covering any costs). Part B does not have a deductible requirement, but it may require a monthly premium.

In order for Medicare to pay for long-term nursing home care, the individual must have a minimum of three consecutive days of hospitalization prior to entering the nursing home and the condition must be certified by a doctor as requiring daily skilled nursing care or physical therapy.

In addition, the individual must meet other criteria, including passing a screening for medical necessity and being able to benefit from the care received at the nursing home in order for Medicare to cover the cost of the services.

Eligibility Criteria for Medicare to Pay for Long-Term Nursing Home Care

Medicare is a federal health insurance program designed to provide coverage to those age 65 and older or certain individuals under the age of 65 who have certain medical conditions. Medicare offers coverage for long-term nursing home care but there are certain eligibility criteria that must be met in order for Medicare to pay for this type of care.

In order for an individual to be eligible for Medicare to cover long-term nursing home care, they must:

Be a U.S. citizen or have been residing in the United States for at least five years
Be age 65 or older
Have a disability or have certain medical conditions such as end-stage renal disease (ESRD)
Be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance)

If an individual meets all of these criteria, then they may be eligible for Medicare to cover some or all of their long-term nursing home care expenses. However, there are other factors to consider when determining if an individual will qualify for Medicare coverage of long-term nursing home care.

In addition to meeting the eligibility criteria listed above, individuals must also meet certain medical criteria to qualify for Medicare to cover their long-term nursing home care expenses. Medicare requires that a beneficiary must require continuous daily skilled nursing care and/or rehabilitation services to be eligible for coverage.

It is important to note that Medicare does not pay for custodial care needs such as help with activities of daily living like bathing, dressing, and meal preparation. Medicare only pays for services that are medically necessary and skilled nursing or rehabilitation services are considered medically necessary. Custodial care may be covered by other sources, such as long-term care insurance, Medicaid, or private pay.

What Types of Services Medicare Covers When Paying for Long-Term Nursing Home Care?

Long-term nursing home care can be an expensive expense, but Medicare can help cover some of the costs. When it comes to long-term nursing home care, Medicare covers certain services and treatments that are considered medically necessary.

Medicare will cover services and treatments that are considered necessary for treating a medical condition, such as physical therapy and speech-language pathology. It also covers other services, such as skilled nursing care, occupational therapy, and medical social services.

Medicare will also cover certain medications and medical supplies that are necessary for treating a medical condition. This includes drugs used to treat pain, as well as items such as catheters, blood transfusions, prosthetics, and medical equipment.

In addition, Medicare will pay for certain supportive services that are needed to treat a patient’s condition, such as meals, personal care, transportation, and recreational activities.

Finally, Medicare will cover some home health services, which can include nursing care, physical therapy, occupational therapy, and speech-language pathology. These services can be provided in the home or in a nursing home setting.

When considering all of these services, it is important to note that not all services that Medicare covers under long-term care will be covered in full. Some services may require co-pays or have limits on what is covered, so it is important to read through the details of your plan before signing up.

How Much Does Medicare Pay for Long-Term Nursing Home Care?

When considering long-term nursing home care, the cost can be a significant factor. While many health plans will cover a certain percentage of the cost, it's important to know what you can expect from Medicare when covering the expenses for long-term nursing home care.

Medicare is a health insurance program that provides coverage for people aged 65 and over, or those under 65 with certain disabilities or conditions. It is funded by the federal government and offers a range of benefits for healthcare.

Medicare will typically pay for part of the costs associated with long-term nursing home care. Depending on the type of care received, Medicare will cover some or all of the cost. The specific level of coverage will depend on the type of care being provided and the amount of time spent in a nursing home.

For skilled nursing care, Medicare Part A will cover up to 100 days in a nursing home provided that certain criteria are met. In order to qualify for this coverage, the beneficiary must have been recently hospitalized for three or more consecutive days. In addition, at least one of the treatments received while in the hospital must be related to the illness or condition that necessitated the stay in a nursing home.

Medicare Part A also covers some forms of custodial care in a nursing home setting. This type of care is designed to improve quality of life and can include help with activities of daily living such as bathing, dressing, and eating. However, Medicare Part A does not pay for long-term custodial care and will only provide coverage for a maximum of 100 days in a nursing home.

Medicare Part B may also provide coverage for nursing home care in certain circumstances. For example, if the services required by the patient are medically necessary, Medicare Part B may pay some or all of the cost. However, it should be noted that Medicare Part B does not cover custodial care, nor does it cover room and board.

It's important to note that Medicare does not pay for all of the costs associated with nursing home care. Out-of-pocket expenses for long-term nursing home care can include medical deductibles, coinsurance, copays, and other services not covered by Medicare. Therefore, it is important to speak to your healthcare provider or Medicare specialist about the cost breakdown of long-term nursing home care before making a decision.

Costs Not Covered by Medicare for Long-Term Nursing Home Care

When considering a nursing home, it is important to be aware of the costs that are not covered by Medicare. Many people are surprised to learn that Medicare does not cover everything when it comes to long-term nursing home care. These costs can add up quickly, so it is important to understand what they are and how you can best manage them.

The following are some of the expenses that are not covered by Medicare when it comes to long-term nursing home care:

Non-medical expenses such as meals, recreational activities, laundry services, etc.
Transportation expenses
Charges for private rooms
Prescription drugs not covered by Medicare Part D
Medical supplies that are not otherwise covered under Medicare
Certain specialized therapies such as physical, occupational, or speech therapy

It is important to remember that while Medicare may cover some of these expenses, a person is still responsible for any copayments or coinsurance associated with those services. Additionally, there may be additional charges associated with certain services or treatments that are not covered by Medicare.

For those who are considering a nursing home, it is important to factor in all of these potential costs before making a decision. It can be beneficial to research and compare costs from different facilities in order to get an accurate idea of how much it may cost for a stay at a particular nursing home.

Considerations When Choosing a Nursing Home Covered by Medicare

When a person or their loved ones decide to move into a nursing home, there are several factors that should be taken into consideration when selecting a nursing home covered by Medicare. While most states have long-term care facilities that are approved by Medicare and provide necessary services, it is important to make sure the nursing home you choose has the resources and amenities needed for a comfortable and healthy lifestyle.

The following are important considerations to make when choosing a nursing home covered by Medicare:

Location: The location of the nursing home is an important factor. Be sure to research the facility and its surrounding environment to ensure there is easy access to amenities such as hospitals, pharmacies, shopping centers, and restaurants. It is also important to check what kind of public transportation is available in the area.
Services: Make sure to investigate what type of services the nursing home provides, such as short-term rehabilitation, dementia care, respite care, and hospice. Be sure to inquire about staffing levels and quality of care, as well as any additional services they may offer for specific health-care needs.
Costs: Costs can vary depending on the type of care needed and the services offered at the facility. Compare prices between different nursing homes, and ask about copayment policies and any additional fees that may be charged.
Activities: Nursing homes should provide enriching activities for residents to engage in. Ask about the types of activities they offer, such as music programs, exercise classes, group outings, religious services, and other recreational activities.
Accommodations: Investigate the living arrangements that are available at the nursing home. Be sure to check the size and layout of the rooms, as well as the food services, housekeeping, and laundry services.
Safety: Look for a nursing home that meets all safety requirements and makes sure its residents are safe from abuse and neglect. Investigate the staff’s background and credentials and ask about infection control procedures and general sanitation. Additionally, ask if there is a secure outdoor space for residents.

Researching and comparing different nursing homes that are covered by Medicare can help you find the best option that meets your needs. Being informed and prepared will make the transition into a nursing home smoother and ensure that the facility you choose provides the quality of care and services you expect.

Many people are concerned about the costs associated with long-term nursing home care, especially if it’s not covered by insurance. Fortunately, Medicare may help cover some of those costs if you meet certain eligibility requirements. In this section, we’ll discuss how to make sure your nursing home care is covered by Medicare.

To begin, it’s important to understand what Medicare typically covers for long-term nursing home care. Generally, Medicare will pay for up to 100 days of medically necessary nursing home care if all the following conditions are met:

You are a Medicare beneficiary and enrolled in Part A
A doctor must certify that you need skilled nursing care on a daily basis
You have been receiving treatment for the same condition or illness for at least three days in a row (this can be hospital care, doctor visits, or other healthcare services)
You receive care at a Medicare-certified nursing home

When planning for long-term nursing home care, it’s important to research the available facilities in your area to make sure they are certified by Medicare. If you’re unsure whether a particular facility is approved, you can call the Medicare hotline at 1-800-MEDICARE and ask.

It’s also important to understand that even if you meet the eligibility requirements, Medicare will only cover a portion of the total cost of nursing home care. Your family may still need to pay out-of-pocket or supplement the costs with a long-term care insurance policy.

It’s also wise to plan ahead for any additional medical needs or expenses that may arise, such as drug prescriptions, transportation to and from doctors’ appointments, and personal care services. Keep in mind that Medicare does not cover these types of costs.

Finally, it’s essential to stay up-to-date on your Medicare coverage and benefits to ensure that you get the most out of your policy. Consider signing up for Medicare’s free email newsletter so you can receive the latest information on changes in the program, as well as tips and advice for making the most of your coverage.

By understanding what Medicare covers and what it doesn’t, you can take the necessary steps to make sure your nursing home care is fully covered. With the right preparation and planning, you can rest assured that your long-term nursing home care will be taken care of.

Frequently Asked Questions Regarding Medicare Coverage for Long-Term Nursing Home Care

Having to make decisions about long-term nursing home care can be incredibly overwhelming. One of the most important points of consideration is how much of the cost will be covered by Medicare.

Here are some frequently asked questions and answers about Medicare coverage for long-term nursing home care:

What types of services does Medicare cover for long-term nursing home care? Medicare offers coverage for skilled nursing services, including physical therapy, speech-language pathology services, and medical social services, as long as your stay is for medically necessary reasons.
What does Medicare not cover for long-term nursing home care? Medicare does not cover custodial care, such as help with bathing or dressing, unless it is in conjunction with skilled nursing services. Medicare also does not cover personal care services, such as help with meals, housekeeping, or errands.
How much does Medicare pay for long-term nursing home care? The amount that Medicare pays for long-term nursing home care depends on a variety of factors, including the type of care you need, the duration of your stay, and your location. On average, Medicare pays between 80% and 100% of reasonable charges.
Are there any other costs associated with long-term nursing home care that aren't covered by Medicare? Yes, there may be additional costs associated with long-term nursing home care that are not covered by Medicare, such as private rooms and special diets. You may be responsible for covering these costs.

It is important to remember that Medicare coverage for long-term nursing home care is complex and varies from state to state. It is best to consult with your healthcare provider or a Medicare specialist to get an accurate idea of what services are covered and what costs you may be responsible for.

The bottom line when it comes to Medicare coverage for long-term nursing home care is that Medicare can provide coverage if you meet the eligibility criteria. It’s important to understand what’s covered and how much Medicare will pay so that you can make an informed decision when choosing a nursing home.

When considering the cost of long-term nursing home care, financial planning and budgeting in advance can help to reduce the financial stress of covering the costs. Knowing which services are covered by Medicare and which are not can also help you make decisions about the right care for you.

When selecting a nursing home, make sure to do your research beforehand to find out if the facility is covered by Medicare and what types of services are available. Additionally, if you or a family member is entering a nursing home, make sure to regularly evaluate their care to ensure that it meets your expectations and that you are getting the appropriate coverage from Medicare.

Taking the time to understand the process of gaining Medicare coverage for long-term nursing home care is worth the effort. While it may seem daunting at first, the knowledge gained through researching options and understanding the details of the Medicare coverage can be hugely beneficial to both yourself and your loved ones.

Finding resources on how much Medicare pays for long-term nursing home care can be overwhelming. Thankfully, there are a number of reliable outlets with information on this topic. The Centers for Medicare and Medicaid Services (CMS) is an excellent source of official information on Medicare and nursing home care. Additionally, websites such as AARP provide helpful resources, such as information on selecting a nursing home. State government sites also provide important information on the availability and cost of long-term care services in their local area. Finally, consumer-focused organizations such as the National Consumer Voice for Quality Long-Term Care offer valuable information and advocacy services.