Paying for a Nursing Home When Medicare Coverage Ends

Because Medicare stops paying for care after a patient’s 100th day in a skilled nursing facility, your loved one will then have to begin paying through an alternative method or move out of the facility. That could mean using private funds or an existing long-term care insurance policy, and care might continue at home or in a senior living community.

You’re likely already thinking about these next steps if this is your family’s situation, which is essential for making sure your loved one continues receiving proper care. To figure out what’s best for you, let’s explore the key differences between nursing homes, skilled nursing care, other types of senior living, and, most importantly, what Medicare covers.

A nursing home provides long-term care for people who need round-the-clock supervision because they have medical needs that prevent them from living independently. Typically, a nursing home resident will have a serious medical condition that necessitates specialized medical care.

For example, a resident may require significant assistance with mobility or need to be given time-sensitive medications on a precise schedule. This care may be provided by licensed practical nurses, certified nursing assistants, and other aides as directed by a registered nurse or doctor’s orders.

Nursing homes also provide other services that support residents’ activities of daily living, which may include bathing assistance and meal preparation.

Does Medicare pay for nursing homes?

No, Medicare will not cover long-term stays in nursing homes. However, Medicare Part A covers skilled nursing care, but only under specific conditions for a limited amount of time.

Can you afford nursing homes?

Skilled nursing is a type of care that provides high-level medical support in a specific setting, such as a skilled nursing facility or nursing home. While some use the terms “skilled nursing facility” and “nursing home” interchangeably, they’re not the exact same type of care, even though their functions are similar.

A skilled nursing facility is typically geared toward providing short-term inpatient skilled nursing care to rehabilitate patients. Care is usually provided by registered nurses. The following types of skilled nursing care may be offered in a skilled nursing facility:

• 24-hour emergency services
• Catheter care
• Feeding tubes
• Injections and IVs
• Pain management
• Respiratory aspiration
• Vital sign monitoring, including heart rate and blood pressure
• Wound care

The overall goal of this type of facility is to return a patient to their home with the ability to live independently.

Does Medicare pay for skilled nursing care?

Yes, Medicare Part A covers skilled nursing care, but only under specific conditions for a limited amount of time.

Under Original Medicare (Parts A and B), there’s no coinsurance payment for the first 20 days. However, day 21 to day 100 will result in a charge of up to $200 coinsurance per day. In addition, the coverage is only for up to 100 days if the patient meets certain criteria. Many patients don’t get a full 100 days of coverage because they no longer have a need for skilled nursing at a certain point. If that’s the case, Medicare coverage ends prior to the 100th day.

Medicare coverage only lasts a maximum of 100 days. After that, your loved one will be expected to pay all costs on their own, or they’ll be required to leave the facility.^[01]

To qualify for nursing coverage under Medicare, your loved one must meet the following conditions:

• Have Medicare Part A
• Have days remaining in their benefit period
• Have a qualifying inpatient hospital stay, typically a three-day stay at the hospital as an inpatient
• Have a doctor decide they need skilled care, which is provided per Medicare’s guidelines
• Receive services through a Medicare-certified skilled nursing facility
• Need skilled care for a specific, hospital-related medical condition that was treated during the qualifying hospital stay, or a condition that started while your loved one was receiving care at the skilled nursing facility for the hospital-related medical condition ^[01]

What does Medicare cover in a skilled nursing facility?

Medicare covers a variety of approved goods and services if your loved one meets the strict eligibility requirements. These services include but are not limited to the following:

• A semi-private room
• Prepared food and dietary counseling
• Skilled nursing care, such as eligible postsurgical care, wound care, and pain management
• Medications
• Medical supplies and equipment used in the skilled nursing facility
• Medical social services, which includes counseling and connection-building to local resources ^[01]

When a loved one leaves a nursing home, they can continue living in a supportive environment, whether that’s at home or in a senior living community. What’s best for your parent will depend on their unique needs.

Your loved one will be responsible for those costs in senior living if they move to a community following a stay in a skilled nursing facility. It’s important to note that Medicare does not cover assisted living, memory care, or many other long-term care options, because Medicare is intended as health insurance, not long-term care insurance.

There’s no doubt that it can feel overwhelming to determine how to cover the cost of senior living, but there are a variety of ways to pay for senior living by care type.

Read more:Medicare, Medicaid, and Long-Term Care

Expert advice for affordable nursing homes

For independent, older adults

If your loved one doesn’t need assistance with ADLs, they may thrive in a 55+ community setting, which could be senior apartments or independent living.

Senior apartments function similarly to non-age-restricted apartments in that your loved one will typically have a lease and will have to care for their own needs.

Independent living offers older adults hassle-free living in a social community atmosphere. These communities have more services and amenities, such as prepared meals, transportation, and organized social activities, than senior apartments do.

As senior apartments and independent living don’t have a medical component, they can’t be paid for by Medicare. Alternative payment options for senior apartments and independent living may include the following:

• Pay privately from your loved one’s retirement funds, savings accounts, stocks, bonds, and more.
• Use your loved one’s life insurance policy to pay for senior living by surrendering its cash value.
• Pay with military retiree and VA benefits, such as military retiree pay, VA disability compensation, or Survivors Pension.

For adults who need extra support

For older adults who need assistance with activities of daily living or need specialized memory care related to a diagnosis of Alzheimer’s disease or other type of dementia, there are more supportive senior living options available.

While assisted living may offer similar amenities to independent living, it stands out for providing residents with assistance with instrumental activities of daily living (IADLs) and some limited ADLs. These communities typically feature engaging activities and tailored amenities to add to seniors’ quality of life and socialization opportunities.

Memory care focuses on providing specialized care personalized to the unique needs of people with memory challenges. Like assisted living communities, memory care communities also offer support for IADLs and some ADLs. However, these communities typically offer a secure atmosphere to keep residents safe and prevent dangerous wandering.

If your loved one prefers a more intimate setting, they may enjoy life at a residential care home. These senior living options tend to be smaller and have a homelike, familiar setting, which can be very welcoming to seniors who are new to life in senior living. They also offer engaging activities and IADLs and limited ADL support.

Again, Medicare will not cover the costs of living in an assisted living community, memory care community, or residential care home — only some medical services that a resident receives while living in one of those communities. The following may be options you can utilize to pay for these senior living options:

• Pay from private sources, such as pensions, bonds, stocks, investments, etc.
• Sell your loved one’s life insurance policy and create a long-term care benefit plan to fund care.
• Pay with military retiree and VA benefits, such as military retiree pay, VA health care, VA disability compensation, or Aid and Attendance if they have a demonstrated need for assistance with at least two ADLs.
• Use your loved one’s long-term care insurance policy to pay for qualified care.
• Utilize a state long-term care waiver program, such as Arizona Long Term Care System, to pay for eligible care.

For those who wish to live at home

It’s common for seniors to wish to remain within the comfort of their own home as they age. With the help of home care and home health care, your loved one can continue to live in familiar surroundings.

While these two options sound similar, home care and home health care differ. Home care provides nonmedical support for IADLs and ADLs to an older adult in their home, whereas home health care provides medical-focused care in a senior’s home environment. It’s important to understand that Medicare typically only covers home health care, while home care is rarely covered.

You may need to consider the following ways to pay for in-home care outside of public assistance:

• Pay from private sources, such as bank accounts, investments, or proceeds from selling a house.
• Sell your loved one’s life insurance policy and create a long-term care benefit plan to fund care.
• Pay with military retiree and VA benefits, such as military retiree pay, VA disability compensation, or Aid and Attendance.
• Use your loved one’s long-term care insurance policy to pay for qualified care.

Figuring out the place or service that best fits your loved one’s unique needs following a short stay in a skilled nursing facility or nursing home can be a challenge. You don’t have to go it alone. The knowledgeable Senior Living Advisors at A Place for Mom can assist you with locating senior care options outside of skilled nursing — all at no cost to your family.