Medicare covers nursing home care for a limited time, not indefinitely

Medicare pays for skilled nursing facility (SNF) care for up to 100 days per benefit period, but only if you meet specific conditions. You must have been hospitalized for at least three consecutive days, enter the nursing home within 30 days of leaving the hospital, and need daily skilled nursing or rehabilitation services — not just help with daily living. After 100 days, you pay the full cost yourself unless you have other coverage like Medicaid or a Medigap plan.

The payment structure changes as your stay continues. Medicare covers all costs for days 1 through 20. From day 21 through day 100, you pay a daily coinsurance amount (this amount changes each year). After day 100 in the same benefit period, Medicare stops paying entirely.

Key Takeaways

  • Medicare covers up to 100 days of skilled nursing facility care per benefit period, but only after a hospital stay of at least three consecutive days.
  • You pay nothing for days 1 through 20; from day 21 through day 100, you owe a daily coinsurance amount that Medicare sets each year.
  • The nursing home must provide skilled care — physical therapy, wound care, or daily nursing services — not custodial care like bathing or meal information alone.
  • Once your 100 days end, Medicare coverage stops for that benefit period, and you must pay out of pocket or use Medicaid if you may have access to.
  • A new benefit period begins October 1 each year, which resets your 100-day count if you need nursing home care again.

What counts as a may have access to hospital stay

You must spend at least three consecutive days in a hospital as an inpatient before Medicare will pay for nursing home care. The three days must be in a row, and the day you are discharged does not count toward the three days. If you go to the hospital, are released the same day, and then admitted to a nursing home, that does not may have access to.

The hospital stay must happen within 30 days before you enter the nursing home. If you leave the hospital, go home for 31 days or longer, and then enter a nursing home, Medicare will not cover that nursing home stay. This 30-day window is strict and does not have exceptions.

The difference between skilled care and custodial care

Medicare only pays for skilled nursing facility care, which means you need medical services that require a nurse or therapist to provide. This includes wound care, physical therapy, occupational therapy, speech therapy, intravenous medications, catheter care, or daily nursing assessment for a medical condition. If a nursing home provides these services and documents that you need them daily, Medicare may cover your stay.

Medicare does not pay for custodial care, which is help with activities of daily living like bathing, dressing, eating, or using the toilet. Many nursing homes provide both types of care. If you need only custodial care, Medicare will not pay, even if you meet the hospital-stay requirement. You would need to pay privately or use Medicaid if you may have access to.

Your doctor and the nursing home determine whether you need skilled care. The nursing home submits documentation to Medicare, which decides whether to cover your stay. If Medicare denies coverage, the nursing home must tell you in writing and explain why.

How the 100-day benefit period works

Your 100 days of coverage are tied to a benefit period, not a calendar year. A benefit period begins the day you enter the hospital and ends 60 days after you leave the hospital or nursing home, whichever is later. If you return to the hospital or nursing home during that 60-day window, the days you already used still count against your 100-day limit.

Once a benefit period ends, a new one begins if you are hospitalized again. A new benefit period gives you a fresh 100 days of nursing home coverage. However, if you use 80 days in one benefit period and then enter a nursing home again in a later benefit period, you get another full 100 days in the new period.

Many people do not use all 100 days. If you need only 30 days of physical therapy after hip surgery, you use 30 days and still have 70 days remaining in that benefit period if you need care again before the period ends.

What you pay on days 21 through 100

Medicare covers all nursing home costs for the first 20 days with no out-of-pocket expense. Starting on day 21, you pay a daily coinsurance amount. This amount is set by Medicare each year and covers part of the nursing home's daily rate; Medicare pays the rest.

The daily coinsurance for 2024 is $200 per day (this amount changes annually). If the nursing home charges more than Medicare's approved rate, you may owe the difference on top of the coinsurance. Some Medigap plans and long-term care insurance policies cover this coinsurance, which is why checking your other coverage before entering a nursing home matters.

You are responsible for paying the nursing home directly or arranging payment. Medicare does not send you a bill; the nursing home bills you for the coinsurance amount each day you stay after day 20.

What happens after 100 days

Once you reach day 101 in the same benefit period, Medicare stops paying. You become responsible for the full daily cost of the nursing home. This can range from $300 to $500 per day or more, depending on the facility and your location. If you cannot pay, the nursing home may discharge you or you may need to explore for Medicaid.

Medicaid is a joint federal and state program that covers long-term nursing home care for people with limited income and assets. Unlike Medicare, Medicaid has no day limit — it can pay for years of care. However, Medicaid rules vary by state, and you must meet income and asset limits. Some people plan ahead by spending down assets or using long-term care insurance to bridge the gap after Medicare ends.

If you have a Medigap plan (supplemental insurance), check your policy to see whether it covers nursing home care beyond Medicare's 100 days. Some Medigap plans do not cover this gap, while others offer limited coverage.

Planning ahead for costs after Medicare coverage ends

Understanding your coverage limits helps you plan for the cost of extended nursing home care. If you think you may need long-term care, talk to a financial advisor or elder law attorney about your options. Some people purchase long-term care insurance years in advance, while others plan to use Medicaid once their savings are depleted.

Before entering a nursing home, ask the facility what Medicare covers and what you will owe after day 100. Request an estimate of daily costs and ask whether the facility accepts Medicaid. If you have a Medigap or Medicare Advantage plan, contact your insurance company to ask what nursing home care is covered.

Keep records of your hospital discharge date and the date you enter the nursing home. These dates determine whether you meet the three-day hospital requirement and the 30-day window. If there is a dispute about coverage, these dates are your proof.

Frequently Asked Questions

Does Medicare pay for nursing home care without a hospital stay first?

No. Medicare requires a hospital stay of at least three consecutive days before it will pay for nursing home care. If you go directly from home to a nursing home, Medicare will not cover it, even if you need skilled care. You would need to pay privately or use Medicaid if you may have access to.

Can I use my remaining days in a new benefit period if I did not use all 100 days?

No. Each benefit period gives you a fresh 100 days. If you use 40 days in one benefit period and then need nursing home care again after that period ends, you get a new 100 days in the next benefit period. Unused days do not carry over.

What if the nursing home says I no longer need skilled care before day 100?

If the nursing home determines you no longer need skilled care, it must notify you in writing. Medicare coverage ends on that date, even if you have days remaining. You can appeal this decision if you believe you still need skilled care. The nursing home must explain the reason for the decision and tell you how to appeal.

Does Medicare Advantage cover nursing home care differently than Original Medicare?

Medicare Advantage plans must cover at least as much skilled nursing facility care as Original Medicare — up to 100 days per benefit period. However, some plans may have additional rules, such as requiring you to use in-network facilities or requiring prior approval. Check your plan's coverage details before entering a nursing home.

If I need nursing home care again after my benefit period ends, do I get another 100 days?

Yes, if you have a new benefit period. A new benefit period begins when you are hospitalized again. Once you meet the three-day hospital requirement and enter a nursing home within 30 days, you get another 100 days of coverage in that new benefit period.