Long-term nursing home costs are usually not covered by Medicare, the federal government’s national health insurance program. However, if someone requires specialized care, certain plans may cover temporary stays in a skilled nursing facility (SNF).
Around 1.3 million adults in the United States live in nursing homes, according to the Centers for Disease Control and Prevention (CDC). Nursing home care is classified by Medicare as either skilled or custodial.
Medicare is divided into four parts, each of which covers a different type of healthcare service, such as hospitalization, outpatient care, and prescription medicines. It can be easier to seek and get healthcare if you know what each plan covers.
When does Medicare cover nursing home care?
Medicare Part A typically covers 100 days of acute treatment in a skilled nursing facility. The person needs to receive competent care every day in order to recuperate.
This level of care is delivered by someone who has had formal medical training, such as a registered nurse or physical therapist. Doctors expect people in skilled nursing facilities to recover from their illnesses or injuries.
Custodial care, such as eating, bathing, or dressing, is not covered by Medicare. Nonmedical care, often known as custodial care, usually entails a long-term stay in a nursing home.
Providing daily care for senior citizens and those with disabilities is a valuable skill. Custodial care providers, on the other hand, are not officially trained doctors or medical professionals.
Visit our Medicare website for more tools to help you navigate the confusing world of medical insurance.
Which parts of Medicare cover nursing homes?
Medicare may cover some or all of the costs of a nursing home. Here’s a rundown of what Medicare might pay for:
Medicare Part A: This part of Medicare covers in-hospital treatment, but it may also cover short-term care in an SNF, including medications.
Medicare Part B: Part B covers outpatient services. It does not usually provide funding for stays in nursing homes.
Medicare Part C: Private companies administer this bundled plan, also known as Medicare Advantage. It does not usually cover long-term custodial nursing home care. However, coverage often depends on the company providing the plan, so exceptions may exist.
Medicare Part D: Part D covers the cost of some or all of the prescription drugs for people who live long-term in a custodial nursing home.
Medigap: These optional plans do not pay for long-term nursing home care. However, Medigap plans may help cover some out-of-pocket costs.
Medicare Part A may fund a stay in a skilled nursing facility if a person is recovering from an illness, injury, or medical treatment.
A doctor must confirm that the person requires competent nursing care on a daily basis. In addition, the person’s benefit period must still be active.
Each benefit period, Part A covers up to 100 days of SNF care. If a person needs to stay longer, they are not eligible for additional coverage.
In addition, they must:
choose a Medicare-certified SNF
enter the SNF after a hospital stay of more than 3 days
receive skilled care for the original health problem for which they received treatment in the hospital or for a condition that developed while they were in the hospital
Here are some services that Medicare Part A may cover in an SNF:
a semi-private room, which usually means that the person shares with one other individual
ambulance transportation to providers of healthcare services that the SNF does not provide
dietary counseling and nutrition services
medical social services
medical supplies and equipment
skilled nursing care, such as intravenous injections
swing bed service, which means that an individual receives SNF care in an acute care hospital
These are the payments due for short-term SNF care:
Days 1–20: Medicare covers the full amount. The insured person pays nothing for each benefit period.
Days 21–100: The insured person pays a $185.50 coinsurance per day for each benefit period.
Days 101 and beyond: The insured person must pay the full costs.
If a person requires services not covered by Medicare, they may have to pay more.
While a person is in a nursing home, Medicare Part C may pay for healthcare or prescription prescriptions. People with particular diseases or healthcare needs may benefit from a Special Needs Plan (SNP).
For information on which services Medicare Advantage plans cover and which copay charges may apply, individuals can contact the plan provider directly.
According to the Centers for Medicare & Medicaid Services, Medicare Part D can assist people to pay for prescription drugs while living in a nursing home. The drugs are provided by a long-term care pharmacy that works with the Medicare plan.
Medigap policies are offered by private insurance firms to augment original Medicare (parts A and B).
Medigap helps cover out-of-pocket expenditures such as copayments and deductibles that Original Medicare does not cover in exchange for a monthly premium.
Long-term care is usually not covered by Medigap. On days 21–100 of SNF care, it can help cover the daily coinsurance.
Ten Medigap plans are defined by federal law. According to the Kaiser Family Foundation, several of these may assist a person in paying for the SNF coinsurance. Individual states, on the other hand, control the plans, and a person cannot receive all of them in each state.
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How to fund nursing home care
The majority of people who live in a nursing home will have to pay for their care with their own money.
Medicaid may be able to assist persons who are in need of a nursing home but have limited income. Not all nursing homes, however, accept Medicaid payments.
A person’s Social Security pension will not cover the price of a nursing facility.
However, in addition to Social Security, some older persons may be eligible for supplementary security income, which could help pay for nursing facility care. A person might examine the Social Security disability program to see if they are eligible for this needs-based program.
Long-term care insurance policies are available from private insurance firms and can cover both skilled and non-skilled care. Depending on the supplier, the terms of these policies may differ. Some insurance policies may pay for nursing home care. Others offer medical coverage for a variety of services.
Long-term care may be covered under an existing life insurance policy.
If a person satisfies certain criteria, Medicare Part A may cover some of the costs of skilled nursing care in a nursing home.
If a person requires long-term custodial care in a nursing home, they will have to pay for it out of pocket. The costs of long-term care may be covered by Medicaid or long-term care insurance.