Does Medicare Pay For Nursing Homes? – Overview
Medicare in the US is a health insurance program for people 65 and older (and those with specified medical conditions).
Studies show that Medicare covered more than 18% of US residents in 2020.
Medicare generally doesn’t cover long-term nursing home costs (the federal government’s national health insurance program).
However, if someone requires specialized care, specialty plans may cover temporary stays in a skilled nursing facility (SNF).
About 1.3 million US citizens live in nursing homes, according to the Centers for Disease Control and Prevention (CDC).
According to Medicare, nursing home care should be either skilled or custodial.
Medicare is divided into 4 parts covering different healthcare services, such as hospitalization, outpatient care, and prescription medicines. It can be easier to seek and get healthcare if you know what each plan covers.
This article examines how Medicare can assist with some nursing home costs, what assistance is available for hospice care insurance, and how to locate a nursing home.
Hospitalizations, outpatient services, and preventive care are all covered under the programs.
To meet the need for specialized care, Medicare pays for short-term nursing homestays.
However, Medicare usually does not pay if a person wants to stay in a nursing home for an extended period.
On What Condition Does Medicare Pays Nursing Home Stay?
If you first understand what Medicare doesn’t cover, it will be easier for you to understand what it covers at a nursing home.
Medicare doesn’t cover the cost of nursing home care when a person only requires custodial care. The following services are included in custodial care:
- Going to the bathroom
Generally, an individual needs care that doesn’t require a degree to provide. Medicare doesn’t cover the service.
So, what does Medicare cover? Let’s discuss this in detail.
Medicare Requirement To Cover A Nursing Home Care
Medicare will pay for skilled nursing care in a nursing home facility if you meet specific criteria. Here are a few of them:
- You must be a Medicare Part A beneficiary with days remaining on your benefit period.
- You must have first completed a required hospital stay.
- Your doctor must determine that you require skilled nursing care. The care should be skilled and provided by a physician or a healthcare professional like a registered nurse, physical therapist, or licensed practical nurse.
- You’ll need to go to a skilled nursing facility for your treatment. In addition, care must be provided daily.
- You must obtain your services at a Medicare-certified facility.
- You require professional services for a hospital-related medical condition or a condition that developed while you were receiving treatment for the original hospital-related medical condition in a skilled nursing facility.
It’s also worth mentioning that this is merely a temporary fix, not a permanent one.
Generally, Medicare Part A may cover a maximum of 100 days of skilled nursing home treatment.
The condition is that one must be admitted to a skilled nursing home within 30 days of being discharged from the hospital, and they must be admitted for the disease or injury due to which they were receiving hospital care.
Note: Medicare should also provide coverage for care that doesn’t require skilled nursing but does require skilled supervision.
Under What Conditions Does Medicare Pays for Nursing Home Care?
Medicare usually covers short-term skilled nursing care in a nursing home.
Part A of Medicare
Medicare Part A usually covers the following services in a nursing home setting.
- Dietary counseling and nutrition services
- Skilled nursing care
- Swing bed services
- Social work medical services
- Medical supplies and equipment
- Dietary counseling and nutrition services
- Speech-language pathology
- Occupational therapy
- Physical therapy
- Semi-private room
Under the conditions mentioned above, a person receives skilled nursing facility care in an acute-care hospital.
Part B of Medicare
Outpatient treatments, such as doctor’s visits and health screenings, are covered. However, nursing home stays are frequently not covered under Medicare Part B.
Do Advantage Plans Cover Nursing Home Stays?
Medicare Advantage or Medicare Part C typically do not cover custodial care in nursing homes, except in a case where a person’s health insurance plan has a contract with a certain nursing home or organization running nursing homes.
Before visiting a nursing home, always check with your plan provider to see what treatments are and aren’t covered under your Medicare Advantage plan.
Medicare Advantage Part C has all benefits of Medicare (Parts A and B).
Many Medicare Advantage plans, unlike Original Medicare, include fees for vision, hearing, and dental care, as well as prescription medicines.
Your coverage may also include nursing home care, depending on which Medicare Advantage Plan you choose. Let’s look at it more closely.
Nursing Home Care and Medicare Advantage
Since it does not cover custodial care, Medicare does not generally cover nursing home care.
However, according to the official US government website for Medicare, most nursing home care is considered custodial care, described as assistance with daily tasks such as eating, dressing, bathing, and using the restroom.
SNF care, according to Medicare, is defined as care that qualified professionals must provide to be safe and effective.
Changing sterile bandages and delivering intravenous antibiotics are 2 examples.
For SNF care, you must pay the following amounts under Medicare:
- For each benefit period, days 1-20 are free.
- Days 21-100: $185.50 per day of each benefit period co-insurance
- All charges from Day 101 onwards
Who Foots The Bill For Long-Term Care?
Medicare does not pay anything toward the high long-term care costs in a nursing home or other institution.
So, who or what is it that does it? Here are a few possibilities.
Private pay: To pay for their own or a loved one’s nursing home care, many people and families pay out of pocket or use assets such as property or investments. If those resources are depleted, Medicaid may become a possibility.
Long-term care insurance: Depending on the conditions of their policies, some people have long-term care insurance that may payout.
The VA: Veterans of the military may be eligible for long-term care benefits from the United States Department of Veterans Affairs.
Medicaid: A state and federal healthcare program that covers low-income persons who qualify pay a significant percentage of nursing-home costs in the United States.
Medicaid eligibility varies by state, although all states have tight income and asset limits.
In need of nursing home care, if you need coverage for nursing home stay care, you can avail of Medicare Advantage Plan, categorized into 6 types as follows. These 6 main types of plans include:
HMO Plans or Health Maintenance Organizations
PPO Plans or Preferred Provider Organization () plans
PFFS plans or Private Fee-for-Service
SNPs Plans or Special Needs Plans
HMO Point-of-Service (HMO-POS) plans
MSA Plans or Medical Savings Accounts
SNPs Plans or Special Needs Plans
SNP is the one that matters in the context of nursing home care. SNPs come in a variety of shapes and sizes.
Institutional SNPs (I-SNPs), according to the Centers for Medicare & Medicaid Services, are specifically created for persons who require various types of qualified long-term care.
The availability of SNPs varies by region, as per the official Medicare website of the United States government.
For example, some companies provide SNPs to all Medicare beneficiaries in a particular state, while others only offer them in specific counties.
Additionally, 1 provider may offer numerous SNPs, while another may only offer a single plan.
Furthermore, an SNP available last year may not be functional this year, as insurance firms can join or leave Medicare every year.
According to the official Medicare website of the United States government, all SNPs provide prescription drug coverage.
In addition, of course, they provide coverage comparable to both Medicare Part A and Medicare Part B.
Medigap supplement policies sold by Private insurance firms help pay additional costs like deductibles.
Co-insurance: Some Medigap plans like C, D, F, G, M, and N may cover Co-insurance for skilled nursing care facilities.
Plans are among them. Plan K covers approximately half of the co-insurance, whereas Plan L covers the other half.
On the other hand, long-term nursing home care is not covered by Medigap supplement insurance.
Medicare Part A covers your prescriptions during this time.
Best Medicare Plans For Nursing Home Care:
Most Medicare plans don’t cover nursing home care. However, if you acquire a Medicare Advantage plan with a special arrangement with a nursing facility, you may be eligible for an exception.
Ways to Assist In Paying For Nursing Home Care:
There are choices outside of Medicare that may assist in offsetting some costs if you or a loved one needs long-term nursing home care. These are some of them:
LTC insurance: It’s a type of long-term care insurance. This could assist in paying for all or part of the costs of a nursing home.
Many people will buy this insurance when they are younger, in their 50s, because rates typically rise as a person ages.
Medicaid: It’s a government-run healthcare program for low-income people and has state and national programs that assist in paying for nursing home care.
Administration for Veterans Affairs: Here, retired military personnel may be eligible for financial help for long-term care services from the US Department of Veterans Affairs.
After exhausting their financial resources to pay for long-term care, some people may require Medicaid services.
What is a Nursing Home?
A nursing home facilitates patients to reside and treats them in-house, and residents can get additional care from nurses or nurses.
Nursing homes are most likely to be homes or apartments for persons who require further daily medical care and cannot be left alone.
Some provide beds, showers, standard restrooms, recreation, relaxing, and dining areas.
Most nursing homes provide 24/7 care services, including assistance with going to the restroom, prescription assistance, and meal services.
Nursing Home Care Advantages
There are several benefits of nursing home care that people can enjoy, which include:
- Nursing home care typically enables people to live independently without performing household tasks such as grass mowing or home maintenance.
- Many nursing homes also offer social activities that allow residents to keep friendships and participate in other activities.
- Having access to needed nursing services and qualified people on hand to supervise a person can bring a sense of comfort to a person and their family.
- Nursing homes are secure and can be especially helpful for patients who need special care to stay safe.
Nursing Home Care Cost
As per a survey by Genworth, from 2004 to 2019, the nursing home care cost in skilled nursing institutions and nursing homes.
They discovered that the average cost of a private room in a nursing home in 2019 is $102,200 per year, up 56.78 percent from 2004.
Likewise, the average care price in an assisted living facility is $48,612 per year, up 68.79 percent from 2004.
Nursing home care is costly; rising prices are attributed to the treatment of increasingly sicker patients, employee shortages, and increased restrictions that drive up costs.
How to Assist a Loved One Enrolling in Medicare
If you have a loved one approaching the age of 65, here are some suggestions for how you might assist them in enrolling:
- You have 3 months before your loved one turns 65 to begin the process. Starting early can help you acquire answers to essential concerns and reduce stress during the process.
- Visit the official website of the Social Security Administration to find a location near you.
- Talk to your friends and family members to see whether they’ve gone through anything similar. They can offer advice based on what they learned while enrolling in Medicare and, if necessary, pick supplement plans.
Medicare Part A covers skilled nursing care in a nursing home setting, provided a person fits specific criteria.
In case of a need to live in a nursing home for a long time to receive custodial care and other services, you’ll almost certainly have to pay out of cash or rely on long-term care insurance or Medicaid.
However, if a person satisfies specific 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. However, Medicaid or long-term care insurance may cover long-term care costs.
I am a dedicated healthcare researcher and an enthusiast specializing in medical grants, medical education and research. Through my articles, I aim to empower healthcare professionals and researchers with valuable insights and resources to navigate these critical aspects effectively.