Medicare coverage for nursing home care ends when you no longer need skilled care
Medicare stops paying for your nursing home stay when your doctor determines you no longer need skilled nursing care — that is, daily medical services like wound care, physical therapy, or medication management that require a nurse or therapist to deliver. Medicare does not pay for custodial care, which is help with daily activities like bathing, dressing, and eating. Once your medical needs drop to that level, your bill becomes your responsibility, and you have limited time to arrange payment or move.
The nursing home must give you written notice at least two days before Medicare stops paying. That notice tells you the exact date coverage ends and explains your right to appeal if you believe you still need skilled care. The notice is your signal to act — contact your family, your social worker, or your insurance company when ready, because your options depend on how quickly you move.
Key Takeaways
- Medicare coverage ends when your medical needs drop to custodial care only, and the nursing home must notify you in writing at least two days before that date.
- You can appeal the decision to stop coverage if you believe you still need skilled nursing care, and the appeal process pauses your bill during review.
- If coverage ends and you cannot pay out of pocket, Medicaid may cover nursing home care if you meet income and asset limits, though the process takes time to complete.
- Some people move to assisted living, adult day programs, or home care when skilled nursing coverage ends, depending on their medical needs and family support.
- Your nursing home social worker can help you explore payment options and connect you with local resources before your coverage date ends.
How Medicare decides when to stop paying
Your doctor and the nursing home care team review your progress regularly. If your condition improves enough that you no longer need daily skilled services — for example, your wound is healed, your therapy is complete, or your medications are stable and you can manage them yourself — Medicare determines that skilled care has ended. This decision is made by the nursing home's medical staff, not by Medicare directly, but Medicare's rules guide what counts as skilled care.
The nursing home must document the reason for the decision in your medical record. Common reasons include: your physical therapy or occupational therapy goals have been met, your wound no longer requires professional dressing changes, your condition has stabilized and you no longer need daily nursing assessment, or your doctor has determined you can safely manage at home or in a less intensive setting. The decision is based on your actual medical needs, not on your age, diagnosis, or how long you have been there.
Your right to appeal the decision
You do not have to accept the nursing home's decision to stop coverage. If you believe you still need skilled care, you can file an appeal with Medicare. The appeal process has several levels, and you have specific time windows to act at each one.
Your first step is to request a Detailed Explanation of Non-Coverage from the nursing home. This document explains exactly why Medicare determined skilled care has ended. You must request it before or on the day coverage ends. Once you have it, you can file a Level 1 Appeal (called a redetermination) with Medicare within 120 days. During the appeal, Medicare continues to pay your nursing home bill while the case is reviewed — you do not have to pay out of pocket while waiting for a decision.
To file the appeal, contact your nursing home's patient advocate or social worker and ask them to help you submit the form, or call Medicare directly at 1-800-MEDICARE. You will need to explain why you believe you still need skilled care — for example, you still cannot safely bathe yourself, your wound still requires professional care, or your medications still need daily nursing monitoring. If Medicare denies your appeal, you can request a Level 2 Appeal (called a reconsideration) within 180 days of the denial.
What to do if your appeal is denied
If Medicare upholds its decision that you no longer need skilled care, your coverage ends on the date the nursing home specified. At that point, you need a plan for payment. Your options depend on your income, assets, and medical needs.
If you have savings or family support, you can pay the nursing home directly. Nursing home costs vary widely by location and facility, but you should ask the business office for your daily rate and total expected cost. Some people use this time to explore whether they can safely move home with family help, move to assisted living (which is less expensive than skilled nursing), or transition to Medicaid coverage if they may have access to.
Medicaid as a payment option after Medicare ends
If you cannot pay out of pocket, Medicaid may cover nursing home care, but only if you meet your state's income and asset limits. Medicaid is a joint federal and state program, so the rules vary by state. Most states allow nursing home residents to keep a small amount of income and assets — typically $2,000 or less in countable assets, though this varies — and Medicaid pays for care once you are below that threshold.
The process of switching from Medicare to Medicaid takes time. You must explore through your state's Medicaid office or your local social services department. The nursing home's social worker can help you start the process, but you will need to provide proof of income, assets, citizenship, and residency. While your process is being reviewed, you are responsible for paying the nursing home bill. Some facilities will hold a bed for a limited time while you wait for Medicaid approval, but this varies — ask the business office about their policy before your Medicare coverage ends.
If you are approved for Medicaid, it will cover your nursing home care going forward, but it may not cover the bill that accumulated while you were waiting for approval. Some states have programs to help cover that gap, and your social worker can tell you whether your state offers one.
Other living arrangements when skilled care ends
Not everyone stays in a nursing home after Medicare coverage ends. Depending on your medical needs and family situation, you might move to a different setting.
Assisted living is less expensive than skilled nursing and may be appropriate if you need help with daily activities but no longer need daily medical care. Home care — either paid or provided by family — is an option if your needs are minimal and your home can be modified to keep you safe. Adult day programs offer social activities and supervision during the day while you live at home. Some people return home with family support and outpatient therapy. Your doctor, the nursing home social worker, and your family should discuss which option makes sense for your situation and budget.
Steps to take before your coverage ends
Do not wait until the coverage end date to plan. As soon as you receive the notice that Medicare is stopping payment, take these steps:
- Ask the nursing home for a written explanation of why skilled care is ending.
- Discuss the decision with your doctor and ask whether you agree that you no longer need skilled care.
- If you disagree, request the Detailed Explanation of Non-Coverage and file an appeal within the time window.
- Meet with the nursing home's social worker to discuss payment options: out-of-pocket payment, Medicaid, moving to a different setting, or returning home.
- If you think you may may have access to for Medicaid, ask the social worker to help you start the process before coverage ends.
- Contact your family or caregiver and let them know the situation so you can plan together.
- Ask about the nursing home's policy on holding your bed if you are waiting for Medicaid approval.
Frequently Asked Questions
Can the nursing home force me to leave on the day Medicare stops paying?
No. The nursing home cannot discharge you when ready just because Medicare coverage ends. Federal law requires the facility to give you reasonable notice and time to arrange alternative care. If you are waiting for Medicaid approval or exploring other options, ask the business office about their discharge policy. Many facilities will hold your bed for a period while you arrange payment, but policies vary.
What if I cannot afford to pay and Medicaid denies me?
Contact your local Area Agency on Aging or your state's Long-Term Care Ombudsman — both can help you understand why you were denied and whether you can appeal. Some states have hardship programs or spend-down rules that allow you to become Medicaid-may be able to access by using your income for care costs. Your social worker can also connect you with local nonprofits that may help cover costs temporarily.
If I appeal and win, does Medicare pay the bill that accumulated while I was waiting?
Yes. If your appeal is successful, Medicare covers the bill retroactively to the date the nursing home said coverage would end. You do not owe that amount out of pocket. This is one reason to appeal promptly if you believe you still need skilled care.
Can I move to assisted living while I wait for Medicaid approval?
Yes, and it may be a good option if assisted living is less expensive than the nursing home and your medical needs have truly dropped to custodial care. However, Medicaid does not cover assisted living in most states — it covers nursing home care and some home care services. Ask your social worker whether assisted living is covered under your state's Medicaid program before you move.
Who pays for therapy or medical visits after Medicare coverage ends?
You do, unless Medicaid covers them. Medicare Part B may still cover outpatient therapy or doctor visits if you are not in the nursing home, but once you are a resident and Medicare skilled nursing coverage ends, Part B does not pay for services provided in the facility. If you move home or to assisted living, you may be able to use Medicare Part B for outpatient services — ask your doctor.