Medicare covers nursing home care only after a hospital stay, and only for skilled care — not custodial or long-term residential care

Medicare will pay for a nursing home stay if three conditions are met: you spent at least three consecutive days in a hospital (not counting the discharge day), a doctor ordered the nursing home care as part of your recovery, and you enter the nursing home within 30 days of leaving the hospital. The care itself must be skilled nursing care — meaning a licensed nurse or therapist must provide it as part of your medical treatment. Physical therapy after a hip fracture, wound care after surgery, or medication management for a new condition all count. Custodial care — help with bathing, dressing, meals, or daily living — does not, even if you need it badly.

This is the single biggest misunderstanding about Medicare and nursing homes. Many people assume Medicare will cover a nursing home stay because they are old and sick. It will not. Medicare is health insurance, not long-term care insurance. It pays for medical treatment in a nursing home, not for a place to live when you can no longer live alone.

Key Takeaways

  • Medicare covers nursing home care only if you had a hospital stay of at least three consecutive days first, and only within 30 days of discharge.
  • The nursing home care must be skilled care ordered by a doctor — physical therapy, wound care, or medical management — not help with daily living.
  • Medicare pays the full cost of days 1 through 20; you pay a daily coinsurance amount (currently $200 per day, though this changes yearly) for days 21 through 100.
  • After 100 days in the same nursing home for the same condition, Medicare stops paying and you or your insurance must cover all costs.
  • If you need a nursing home but have no hospital stay, Medicaid may cover it, but rules vary by state and income limits explore.

The three-day hospital stay requirement

The hospital stay must be at least three consecutive days. A single overnight stay, or two nights, does not count — you need three full calendar days and nights. The day you are discharged does not count toward the three days. So if you enter the hospital on Monday and leave on Thursday, that counts as three days (Monday, Tuesday, Wednesday). If you leave on Wednesday, it counts as two days and you do not meet the requirement.

Observation status complicates this. Some hospitals admit you as an "observation patient" rather than as an inpatient. Observation days do not count toward the three-day requirement, even if you stay three nights. You must be admitted as an inpatient. If you are unsure of your status, ask the hospital billing department or your discharge planner before you leave — this matters for your nursing home coverage.

What "skilled care" means and what it does not

Skilled care is medical or therapeutic treatment that requires a licensed professional — a registered nurse, physical therapist, occupational therapist, or speech-language pathologist. Examples include wound dressing after surgery, intravenous medication, catheter care, physical therapy to regain strength after a fall or fracture, speech therapy after a stroke, and monitoring of a new medication or condition. If the primary reason you need the nursing home is to receive one of these treatments, Medicare may cover it.

Custodial care is help with activities of daily living: bathing, dressing, grooming, toileting, eating, and moving around. A nursing home aide provides custodial care. Medicare does not pay for custodial care, even if you cannot do these things yourself and even if a doctor says you need help. If you need only custodial care — you are recovering from an illness but do not need skilled nursing or therapy — Medicare will not cover the nursing home stay. You or your family must pay out of pocket, or you must turn to Medicaid if you meet income and asset limits.

How much Medicare pays and for how long

Medicare covers 100 percent of the cost for the first 20 days in a Medicare-approved nursing home. From day 21 through day 100, you pay a daily coinsurance amount. That amount changes each year; for 2024 it is $200 per day, but you should confirm the current amount with your nursing home or Medicare. After 100 days in the same nursing home for the same condition, Medicare stops paying entirely. You then pay all costs yourself, or Medicaid takes over if you meet your state's rules.

The 100-day limit resets if you leave the nursing home for 60 consecutive days and then return. So if you stay 60 days, go home for two months, and return, you get another 100 days of coverage. But if you return within 60 days, the clock continues from where it left off.

These daily costs add up quickly. At $200 per day coinsurance for 80 days (days 21 through 100), you would owe $16,000 out of pocket. Many people buy Medigap insurance (supplemental coverage) specifically to cover this coinsurance, or they rely on Medicaid if they become poor enough to meet the income and asset limits.

When Medicaid covers nursing home care instead

If you do not have a may have access to hospital stay, or if you need custodial care rather than skilled care, Medicare will not pay. Medicaid — the joint federal-state program for low-income people — may cover nursing home care, including custodial care, but only if you meet your state's income and asset limits. Medicaid rules vary significantly by state. Some states have higher income thresholds; some count assets differently; some have waiting lists.

Medicaid typically requires you to spend down your savings to a certain level (often around $2,000 in countable assets) before it will pay. This is why nursing home costs are so financially devastating for many families — Medicare covers only skilled care after a hospital stay, and Medicaid requires you to be nearly broke. Long-term care insurance, if you have it, may bridge this gap. If you do not have it and do not meet Medicaid rules, you pay privately.

How to learn about your nursing home stay will be covered

Before you leave the hospital, ask your discharge planner whether your nursing home care will be covered by Medicare. The planner should tell you whether you meet the three-day hospital stay requirement and whether your ordered care is skilled care. Ask for this in writing if possible. If the planner says Medicare will not cover it, ask whether Medicaid might, and get a referral to a social worker who can explain your state's rules.

Once you are in the nursing home, Medicare sends you a notice called "An Important Message About Your Rights." This notice tells you how many days Medicare will cover and when your coverage ends. Read it carefully. If you disagree with the number of days, you have the right to appeal. Contact your nursing home's patient advocate or call Medicare directly at 1-800-MEDICARE.

Your nursing home must also give you a document called the "Skilled Nursing Facility (SNF) Notice of Non-Coverage" if Medicare determines your care is not skilled care. This notice explains why coverage is ending and tells you how to appeal. Do not ignore this notice — you have limited time to request an appeal.

What happens when Medicare coverage ends

When your 100 days are up, or when Medicare decides your care is no longer skilled, your coverage stops. The nursing home must notify you in advance. At that point, you have several options: you can go home (with or without home health care), you can stay in the nursing home and pay privately, or you can move to a different facility that accepts Medicaid if you meet the income limits.

Some people stay in the nursing home and pay privately for a while, then explore for Medicaid once their savings are low enough. This is legal, but it is expensive and requires careful planning. If you think you might need Medicaid, talk to a social worker or elder law attorney before you spend down your savings — the rules about what counts as an asset and how quickly you must spend are complex, and mistakes can delay Medicaid approval.

Frequently Asked Questions

Does Medicare cover nursing home care if I was not in the hospital first?

No. Medicare covers nursing home care only if you had a hospital stay of at least three consecutive days first. If you go directly from home to a nursing home, or if you were in the hospital for fewer than three days, Medicare will not pay for the nursing home. Medicaid may cover it if you meet your state's income and asset limits.

What if the nursing home says my care is no longer skilled and Medicare stops paying?

You have the right to appeal. The nursing home must give you a notice explaining why coverage is ending. You can request an appeal within a certain time frame — ask the nursing home or call 1-800-MEDICARE for the important date. During the appeal, you may continue to stay in the nursing home, though you may have to pay while the appeal is pending.

If I run out of Medicare coverage after 100 days, can I switch to Medicaid?

Yes, if you meet your state's income and asset limits. Medicaid rules vary by state, but generally you must have very limited savings and income. Contact your state Medicaid office or a social worker at the nursing home to find out whether you may have access to and how the process works.

Does Medicare cover nursing home care for dementia or Alzheimer's disease?

Only if the care is skilled nursing or therapy ordered by a doctor — for example, physical therapy after a fall, or management of a new medical condition. Custodial care and supervision, even for someone with dementia, are not covered by Medicare. Medicaid may cover it if you meet income and asset limits.

Can I choose any nursing home, or does it have to be Medicare-approved?

Medicare will only pay if the nursing home is Medicare-certified. Most nursing homes are, but not all. Before you are discharged from the hospital, ask your discharge planner whether the nursing home you want is Medicare-certified. If it is not, Medicare will not pay for your stay there.