What Medicare, Medicaid and Insurance Cover for Nursing Home Care (and What They Don't)
Medicare covers only short-term skilled nursing after a hospital stay. Learn how the 100-day benefit, Medicaid, Medigap and long-term care policies actually work.
Medicare does not pay for long-term nursing home care. Original Medicare (Parts A and B) covers a skilled nursing facility stay only when you need daily skilled care or therapy after a qualifying hospital stay, for a maximum of 100 days per benefit period, and only the first 20 days are fully covered. Long-term custodial care, meaning help with bathing, dressing, eating and supervision, is paid by you, by Medicaid if you qualify, or by long-term care insurance. Understanding that split is the single most important step in planning.
Medicare Part A skilled nursing facility benefit
Medicare Part A can help pay for a stay in a Medicare-certified skilled nursing facility (SNF) if all of these are true:
- You had a qualifying inpatient hospital stay of at least three consecutive days, counting the day of admission but not the day of discharge.
- You enter the SNF generally within 30 days of leaving the hospital.
- A doctor certifies that you need daily skilled nursing or skilled rehabilitation (for example physical therapy five or more days a week) for a condition related to the hospital stay or a condition that started during the SNF stay.
- The facility is Medicare certified.
Time spent in the hospital under observation status does not count as inpatient time, even if you were in a hospital bed overnight. Ask the hospital every day whether you are an "inpatient" or "outpatient under observation," because this single label can decide whether Medicare pays for rehab afterward.
The 100-day schedule
| Days in the benefit period | What you pay under Original Medicare |
|---|---|
| Days 1 to 20 | $0 for covered services |
| Days 21 to 100 | A daily coinsurance set each year by CMS ($217 per day in 2026, according to CMS; confirm on Medicare.gov) |
| Day 101 and beyond | All costs |
A benefit period begins when you are admitted as an inpatient and ends after you have gone 60 days in a row without inpatient hospital or skilled nursing care. A new benefit period can restart the 100-day clock, but you must again meet the three-day rule.
Worked example (illustrative): Mrs. R. has a qualifying hospital stay and then needs 45 days of skilled rehab. Days 1 to 20 cost $0. Days 21 to 45 are 25 days at the daily coinsurance. At $217 per day that is 25 x $217 = $5,425. A Medigap plan or other supplemental coverage may pay part or all of that coinsurance.
Medicare's coverage depends on your need for skilled care, not on whether you are improving. Under the settlement in Jimmo v. Sebelius, skilled care to maintain a condition or slow decline can be covered if it requires skilled professionals. Many residents are told they have "plateaued" when the rule says otherwise, so ask for the reason in writing.
When Medicare coverage ends
Before skilled coverage stops, the facility must give a Notice of Medicare Non-Coverage at least two days before. You have the right to a fast appeal through your area's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The notice lists the deadline, which is usually noon of the day before coverage ends, and the phone number. Calling in time can keep coverage going while the appeal is decided. See the rehab stay timeline for how this fits into a typical stay.
Medicare Advantage plans
If you are enrolled in a Medicare Advantage plan (Part C), the plan must cover the same skilled nursing benefits as Original Medicare, but the rules can differ. Many plans use provider networks, require prior authorization and may waive the three-day hospital stay requirement. Cost-sharing may be a flat daily copay instead of the Original Medicare schedule. Always call the plan before admission and ask three questions: Is this facility in network? Has the stay been authorized? What is my daily copay and from which day?
What Medicare does not cover
- Custodial care when it is the only care you need.
- Room and board in a nursing home for a long-term stay.
- Private rooms unless medically necessary.
- Personal convenience items such as television and telephone.
If you stay as a private-pay long-term resident, Medicare Part B still pays for covered doctor visits and outpatient services, and Part D for prescription drugs, but not for the room and care.
Medicaid
Medicaid is a joint federal and state program, and it is the largest payer of long-term nursing home care in the country. To qualify you generally must:
- Need a nursing facility level of care as determined by the state.
- Meet your state's income and asset limits (for a single applicant, countable assets are often limited to about $2,000, but the figure varies by state).
- Be in a Medicaid-certified bed.
Some assets are exempt, such as a primary home (subject to an equity limit that is adjusted annually and varies by state), one vehicle, personal belongings and certain prepaid funeral arrangements. When you receive Medicaid in a nursing home, most of your monthly income goes toward the cost of care, and you keep a small personal needs allowance (federal law sets a floor of $30 per month; states may allow more). Medicaid pays the remainder. Married couples receive special protections so that the spouse still at home can keep a share of the couple's assets and income. Read Medicaid look-back and spend-down basics for details.
Federal law also requires states to seek estate recovery from the estates of certain Medicaid recipients after death, so ask your state agency how it applies to a home.
Medigap (Medicare Supplement) insurance
Medigap policies can pay the SNF daily coinsurance for days 21 to 100. Most standardized plans include this benefit. Medigap does not pay for long-term custodial care. If you have a Medigap policy, it can reduce the cost of a rehab stay, but it will not fund an extended stay after day 100.
Long-term care insurance
A traditional long-term care policy pays a daily or monthly benefit when you cannot perform a set number of activities of daily living (usually two of six) or have severe cognitive impairment. Key terms to understand:
| Policy term | What it means |
|---|---|
| Elimination period | A waiting period, often 30 to 90 days, during which you pay out of pocket before benefits begin. |
| Daily or monthly benefit | The maximum the policy pays per day or month. |
| Benefit period or pool | How long or how much the policy will pay in total. |
| Inflation protection | Whether the benefit grows each year to keep up with rising prices. |
Policies differ, and many pay a fixed dollar amount rather than the full bill, so a policy with a benefit of $200 per day against a $330 per day bill leaves $130 per day for you. Hybrid life insurance and annuity products with long-term care riders are also sold. State Partnership programs let some policy holders protect additional assets if they later apply for Medicaid.
Veterans benefits
Eligible veterans and surviving spouses may qualify for the VA Pension with Aid and Attendance or Housebound benefits, which can add to monthly income, though strict income, net worth and wartime service rules apply. The VA also operates community living centers, and states run veterans homes. Visit VA.gov for current eligibility. Beware of unaccredited "advisors" who charge fees to file claims; the VA maintains a list of accredited representatives.
Putting numbers on your situation
Use the Monthly Out-of-Pocket Calculator to enter a monthly bill, any percentage-based coverage and fixed monthly income. A common starting point for a long-term resident is 0% coverage and the resident's monthly income as the fixed amount. If a $9,500 bill is offset by $2,800 of income, $6,700 per month, or $80,400 per year, remains.
Frequently asked questions
Does Medicare pay for assisted living?
No. Medicare does not pay for room and board in assisted living. Some state Medicaid programs pay for services in assisted living through waivers, but availability varies.
Is the three-day rule waived for Medicare Advantage?
Many Medicare Advantage plans waive it, but not all. Check your plan documents or call the plan before admission.
Can I get Medicaid and Medicare at the same time?
Yes. People who qualify for both are called dual eligible. Medicare pays first for covered skilled care, and Medicaid may pay cost-sharing and long-term care.
Where can I get free counseling?
Every state has a State Health Insurance Assistance Program (SHIP) that offers free, unbiased Medicare counseling. Find yours at the SHIP national resource site or by calling 1-800-MEDICARE.
Sources
- Medicare.gov — skilled nursing facility care, benefit periods and costs
- Medicaid.gov — federal overview of long-term services and supports
- Centers for Medicare & Medicaid Services — annual Medicare cost-sharing amounts
- Department of Veterans Affairs — Aid and Attendance and pension benefits
- SHIP National Technical Assistance Center — free Medicare counseling by state
