Medicare covers nursing home care for up to 100 days per benefit period, but only if you meet specific conditions

Medicare will pay for skilled nursing facility (SNF) care — the medical and nursing services you receive in a nursing home — but the coverage is limited and conditional. You get up to 100 days per benefit period, which is a calendar year that starts when you are first admitted to the hospital. The catch is that Medicare only pays if you were hospitalized for at least three consecutive days first, and only if the nursing home care is a continuation of treatment for the condition that sent you to the hospital.

The first 20 days are fully covered by Medicare. Days 21 through 100 require you to pay a daily coinsurance amount, which varies by year. After day 100, Medicare stops paying entirely, and you become responsible for all costs — or you must turn to Medicaid, private insurance, or out-of-pocket payment.

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.
  • Days 1 through 20 are fully covered by Medicare; days 21 through 100 require you to pay a daily coinsurance amount that changes each year.
  • The nursing home care must be for a condition related to your hospital stay, not for a new or unrelated illness.
  • After 100 days, Medicare coverage ends and you must pay out of pocket, turn to Medicaid, or use another payment source.
  • A new benefit period begins each calendar year, which means your 100-day clock resets if you are hospitalized again in a new year.

The three-day hospital stay requirement

Medicare will not pay for nursing home care unless you spent at least three consecutive days in a hospital when ready before admission to the nursing home. The three days must be for acute care — not observation, not emergency room time alone, but actual inpatient hospital days. This rule trips up many people because a long emergency room visit does not count, even if you are admitted to the hospital late in the day.

The nursing home admission must also happen within a specific window. Medicare generally covers nursing home care that begins within 30 days of your hospital discharge, though some cases allow up to 60 days if there is a gap in care. If you wait longer than that, you lose the connection to the hospital stay and Medicare will not pay.

What "related to your hospital stay" actually means

The nursing home care must treat the same condition — or a condition that arose from — your hospital stay. If you were hospitalized for pneumonia and admitted to a nursing home for pneumonia recovery and physical therapy, that is covered. If you were hospitalized for pneumonia but admitted to the nursing home because your arthritis flared up, Medicare will not pay for the arthritis care.

This rule is stricter than many people expect. Your doctor and the nursing home must document in your medical record that the skilled nursing care is medically necessary for your hospital condition. If you develop a new, unrelated problem while in the nursing home, Medicare will not cover treatment of that new problem — though it will continue to cover care for the original condition.

How the 100-day limit works across benefit periods

A benefit period runs from January 1 to December 31 each calendar year. When you are admitted to a hospital in January and then to a nursing home, your 100 days of coverage count down from that admission. If you use 60 days in January through March, you have 40 days left in that benefit period.

If you are discharged from the nursing home and do not return to the hospital, your remaining days are gone — they do not roll over to the next year. However, if you are readmitted to the hospital in the same calendar year and then to a nursing home again, you start a new 100-day count. A new benefit period also begins on January 1, so if your first nursing home stay ends in November and you are hospitalized again in December, you get another full 100 days of coverage in the new year.

What you pay on days 21 through 100

Medicare Part A covers the full cost of your nursing home care for the first 20 days. Starting on day 21, you pay a daily coinsurance amount. This amount changes each year and is set by Medicare. In recent years, the daily coinsurance has been around $200 to $210, but you should contact Medicare or your nursing home's billing department to confirm the current amount for the year you are admitted.

Some people have supplemental insurance (Medigap) that covers part or all of this coinsurance. Others have employer retiree coverage or union benefits that help. If you do not have supplemental coverage and cannot afford the daily cost, you may turn to Medicaid once your Medicare coverage ends or your resources are depleted — but Medicaid rules vary by state, and you should speak with a social worker at the nursing home about your state's rules.

What happens after day 100

On day 101, Medicare stops paying. You are responsible for the full daily cost of the nursing home, which can range from $100 to $300 per day or more depending on the facility and your location. If you cannot pay out of pocket, you have a few options.

Medicaid may cover nursing home care if you meet your state's income and asset limits. Many people "spend down" their savings to become Medicaid-may be able to access, meaning they use their own money to pay the nursing home until their resources fall below the state threshold. This is a major financial decision and you should discuss it with a social worker, elder law attorney, or financial advisor before it happens. Some states have special rules that protect a spouse's income and assets, so the rules are not the same everywhere.

Private long-term care insurance, if you have it, may pick up costs after Medicare ends. Some families pay out of pocket for as long as they can. Others move the person to a less expensive facility or to home care. There is no single answer, but planning ahead — before you need nursing home care — makes the transition much less chaotic.

How to find out your current coverage status

When you are admitted to a nursing home, the facility's billing department should give you a document called the "Notice of Medicare Non-Coverage" (NOMNC) if Medicare determines your stay is not covered or will not be covered beyond a certain point. This notice explains why Medicare is denying or limiting coverage and tells you how to appeal.

You can also call Medicare directly at 1-800-MEDICARE to ask about your specific situation. Have your hospital discharge papers and nursing home admission date ready. Medicare can tell you whether your hospital stay meets the three-day requirement and whether your nursing home care is considered related to your hospital condition.

Your nursing home's social worker or patient advocate can also help you understand your coverage. They work with Medicare regularly and can often explain your benefits in plain language and help you navigate appeals if coverage is denied.

Frequently Asked Questions

Does observation status in the hospital count toward the three-day requirement?

No. Observation status is outpatient care, not inpatient hospital care, so it does not count. You need three full days as an inpatient. If you are in observation for two days and then admitted as an inpatient for one day, that is only one inpatient day. This is a common source of confusion because you may feel like you are in the hospital, but Medicare counts only inpatient days.

Can I use my remaining days if I leave the nursing home and come back later?

Yes, if you return in the same benefit period (same calendar year) and were hospitalized again before returning to the nursing home. If you straightforward leave the nursing home and come back without a new hospital stay, you do not get to restart your 100-day count — the days you already used are gone. If you are hospitalized again, you may start a new 100-day period.

What if my doctor says I need more than 100 days of nursing home care?

Medicare will not extend coverage beyond 100 days in a benefit period, even with a doctor's recommendation. Your options are to pay out of pocket, turn to Medicaid if you meet the income and asset limits, use private insurance if you have it, or discuss a discharge plan with the nursing home's social worker. Some people transition to home health care or assisted living instead.

Do I have to pay the daily coinsurance if I have Medigap insurance?

It depends on your Medigap plan. Some Medigap plans cover the daily coinsurance for days 21 through 100; others do not. Check your Medigap policy documents or call your insurance company to find out what your plan covers. If you do not have Medigap, you are responsible for the full daily amount.

Will Medicare cover nursing home care if I was not hospitalized first?

No. Medicare skilled nursing facility coverage requires a prior hospital stay of at least three consecutive days. If you need nursing home care but were not hospitalized, Medicare will not pay. You would need to pay out of pocket, use Medicaid if you meet the requirements, or use private insurance or other resources.