What Medicare and TRICARE Actually Cover in a Nursing Home

Medicare covers up to 100 days in a skilled nursing facility (SNF) per benefit period, but only if you meet specific conditions. TRICARE covers nursing home care differently depending on which TRICARE plan you have and whether you are on active duty, retired, or a family member. Neither program pays for custodial care — the help with daily tasks like bathing and dressing — which is what most people need long-term. Both programs pay only for skilled nursing care, which means medical treatment that requires a nurse or therapist.

The length of coverage depends on what you need, not on how long you want to stay. If you recover and no longer need skilled care, both programs stop paying even if you have days left. If you still need skilled care after your covered days end, you pay out of pocket or Medicaid takes over if you may have access to.

Key Takeaways

  • Medicare covers up to 100 days in a skilled nursing facility per benefit period, but only after a hospital stay of at least three days and only for skilled nursing or therapy — not custodial care.
  • You pay nothing for days 1–20, a daily copay (currently $194.50 per day in 2024, though this changes yearly) for days 21–100, and all costs after day 100.
  • TRICARE coverage varies by plan: TRICARE Prime and Select cover skilled nursing care at a copay, while TRICARE for Life covers it as a Medicare supplement after you turn 65.
  • Both programs stop paying the moment you no longer need skilled care, even if you have covered days remaining.
  • If you exhaust Medicare coverage or do not may have access to, Medicaid may cover nursing home care, but you must meet income and asset limits that vary by state.

How Medicare's 100-Day Benefit Works

Medicare's skilled nursing facility benefit begins only after you have spent at least three consecutive days in a hospital. The clock starts on day one of your nursing home stay, not the day you were admitted to the hospital. You must be admitted to the SNF within 30 days of leaving the hospital, or you lose the connection and have to start a new benefit period.

Days 1 through 20 are fully covered by Medicare — you pay nothing. On days 21 through 100, you pay a daily copay. That copay amount changes each year; for 2024 it is $194.50 per day. After day 100, Medicare pays nothing, and you are responsible for the full cost unless another program takes over.

The 100 days reset each benefit period. A benefit period starts when you are admitted to the hospital and ends 60 days after you leave the skilled nursing facility. If you are readmitted to the hospital after that 60-day window closes, a new benefit period begins and you get another 100 days.

What "Skilled Care" Means and When Coverage Stops

Skilled nursing care is treatment that only a licensed nurse can provide — wound care, injections, catheter management, or monitoring of a medical condition. Skilled therapy includes physical therapy, occupational therapy, or speech therapy ordered by a doctor to help you recover function. If you need only help with bathing, dressing, eating, or toileting, that is custodial care, and Medicare does not cover it.

A nurse at the facility must document that you still need skilled care. Medicare reviewers look at your medical record to decide whether you are making progress toward recovery or whether you have plateaued. If the facility or Medicare determines you no longer need skilled care, coverage ends when ready — you do not get to use the remaining days. This is the most common reason people's coverage stops before day 100.

You have the right to appeal if Medicare or the facility says you no longer need skilled care. You can ask for a detailed explanation and request a review, but you must act quickly — usually within days of receiving the notice.

TRICARE Coverage for Nursing Home Care

TRICARE Prime and TRICARE Select both cover skilled nursing facility care at a copay, typically $25 to $40 per day depending on your plan and status (active duty, retired, or family member). Coverage is usually limited to 60 days per benefit year, though some plans allow more. You must use a TRICARE-authorized facility, and your doctor must order the care.

TRICARE for Life, which covers people 65 and older who also have Medicare, works as a supplement to Medicare. It covers the copays and coinsurance that Medicare does not pay, so you have minimal out-of-pocket cost for the first 20 days and the daily copay for days 21–100. After Medicare coverage ends, TRICARE for Life does not extend the benefit — you are responsible for costs.

Active duty service members have different coverage through their military treatment facility or TRICARE Prime. Family members of active duty members should verify their specific plan limits with their TRICARE regional contractor, as coverage varies.

What Happens After Medicare and TRICARE Coverage Ends

Once your covered days are exhausted, you must pay the full cost of nursing home care out of pocket, or you must may have access to for Medicaid. The average cost of a semi-private room in a nursing home ranges widely by region — from under $7,000 per month in some rural areas to over $15,000 per month in urban areas — but these are estimates and actual costs vary significantly.

Medicaid covers long-term nursing home care for people who meet income and asset limits. Those limits vary by state. In most states, your monthly income must be below a certain threshold (often around $2,000 to $2,500 for a single person), and your countable assets must be below a limit (often around $2,000). Your home, one vehicle, and some personal items do not count toward the asset limit, but savings, investments, and other property do.

To transition to Medicaid, you must first spend down your assets to the state limit. Some people use a Medicaid planning attorney to structure this legally, but you can also straightforward pay your nursing home bills until you reach the limit. Once you may have access to, Medicaid takes over and covers the full cost of care.

How to Check Your Remaining Days and Appeal Decisions

You can check how many skilled nursing facility days you have used in the current benefit period by logging into your Medicare account at Medicare.gov or by calling 1-800-MEDICARE. Your nursing home social worker can also request this information on your behalf. Ask for a detailed breakdown of which days were covered and why, if any days were denied.

If Medicare or your facility says you no longer need skilled care, you will receive a notice called a "Notice of Noncoverage." You have the right to request a detailed explanation and to appeal the decision. You can ask for a peer review, which means a different Medicare contractor will look at your case. You must request the appeal within a specific timeframe — usually within days of the notice — so act quickly if you disagree.

Your nursing home ombudsman (a free advocate for residents) can help you understand the notice and file an appeal. To find your local ombudsman, contact your state's Long-Term Care Ombudsman program or call 1-855-500-3537.

Planning Ahead: What to Know Before Admission

Before you or a family member enters a nursing home, ask the facility whether it accepts Medicare and TRICARE, and confirm the copay amounts. Ask the social worker to explain the facility's process for documenting skilled care and how they communicate with Medicare about your progress. Request a written estimate of how long skilled care is expected to last, though this is an estimate and may change.

If you have savings, consider whether you want to use them to extend your stay after Medicare coverage ends, or whether you plan to transition to Medicaid. Some families hire a Medicaid planning attorney to structure their finances before admission, which can protect assets for a spouse or other family members. This is optional but worth exploring if you have significant assets.

Keep copies of all medical records, therapy notes, and Medicare notices. These documents are essential if you need to appeal a coverage decision or if you transition to Medicaid later.

Frequently Asked Questions

Can I use my 100 Medicare days across multiple nursing homes?

Yes. Your 100 days are tied to the benefit period, not to a single facility. If you move to a different skilled nursing facility during the same benefit period, the days you already used count against your total. You still have the remaining days available at the new facility.

What if I need nursing home care but was never hospitalized?

Medicare's skilled nursing facility benefit requires a prior hospital stay of at least three days. If you go directly from home to a nursing home, Medicare does not cover it. You would need to pay out of pocket or may have access to for Medicaid. TRICARE may cover skilled nursing care without a hospital stay, depending on your plan.

Does Medicare cover the cost of the room itself, or just medical care?

Medicare covers the room, meals, nursing care, therapy, and medical supplies as part of the skilled nursing facility benefit. It does not cover items like phone service, television, or personal care items. Those are your responsibility.

If I improve and leave the nursing home early, do I get my copay days back?

No. Once you use a day, it is counted against your 100-day benefit, even if you are discharged early or recover faster than expected. The benefit does not refund unused days.

Can I switch from Medicare to Medicaid while I am in the nursing home?

Yes. Once you spend down your assets to your state's Medicaid limit, you can explore for Medicaid and it will take over payment. The nursing home will continue your care during the transition. The process takes several weeks, so notify the social worker as soon as you think you will may have access to.