Medicare Rarely Pays for Nursing Home Care

Dan Frith

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We hear comments all the time from elders who believe that Medicare will pay for nursing home care. These same people are shocked to learn the reality is far different than what they assumed to be true!

Medicare's coverage of nursing home care is quite limited. Medicare covers up to 100 days of "skilled nursing care" per illness, but there are a number of requirements that must be met before the nursing home stay will be covered.

In order for a nursing home stay to be covered by Medicare, you must enter a Medicare-approved "skilled nursing facility" or nursing home within 30 days of a hospital stay that lasted at least three days. The care in the nursing home must be for the same condition as the hospital stay. In addition, a physician must determine you need "skilled care" and order the treatment. The treatment must be provided daily by a registered nurse, physical therapist, or licensed practical nurse. Finally, Medicare only covers "acute" care as opposed to custodial care. This means it covers care only for people who are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing.

Once you are in a facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Medicare covers 100 percent of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment ($128 a day in 2008). This copayment may be covered by a Medigap policy. After 100 days are up, you are responsible for all costs.

So...beware of thinking that Medicare will pay those nursing home bills...as that is rarely true!

For more information on this subject, please refer to the section on Medical Malpractice and Negligent Care.