How is Nursing Home Care Paid?
Nursing Home Coverage – Quick Facts (2025)
Medicare Part A covers 100% of Medicare-eligible skilled nursing care for Days 1–20 (after a qualifying 3-day inpatient hospital stay).
Medicare still covers care, but you owe a daily coinsurance of $209.50 (2025). This can be paid by Medigap, some retiree plans, or Medicaid.
Medicare stops. You either private pay or qualify for Medicaid (which can cover long-term custodial care).
Medicare covers short-term skilled rehab. Medicaid covers long-term custodial (help with ADLs) if you meet medical & financial rules.
Yes, for Medicare SNF: a 3-day inpatient hospital stay (ER/observation don’t count), and SNF admission within 30 days.
Medicaid allows a Monthly Maintenance Needs Allowance (up to $3,948 in 2025) to protect the community spouse’s income.
Who actually pays for nursing home care—and when does each payer step in?
Many families discover the rules only when a loved one is admitted. In short: Medicare pays for short-term skilled nursing rehabilitation; Medicaid can cover long-term custodial nursing home care if financial and medical criteria are met; and when Medicare ends (or doesn’t apply), costs are covered by private pay, Medigap/retiree plans (coinsurance only), or Medicaid.
How does the “Days 1–20, 21–100, 100+” timeline affect who pays?
Medicare’s coverage of skilled nursing changes with time: first 20 days fully covered, then a daily coinsurance from Day 21 through Day 100, and nothing after Day 100. That’s where supplement insurance or Medicaid may help—or where private pay begins.
Who pays for nursing home care across the common coverage combinations?
| Types of Coverage Held by Nursing Home Resident | Days 1–20 in a Nursing Home | Days 21–100 in a Nursing Home | After 100 Days in a Nursing Home |
|---|---|---|---|
| Medicare Only (No Supplemental Insurance) | Medicare pays 100% (Skilled) | Beneficiary pays $209.50/day coinsurance (2025) | Private pay |
| Medicare with Medigap Policy* | Medicare pays 100% (Skilled) | Medigap typically pays $209.50/day coinsurance | Private pay |
| Medicare with Medicaid | Medicare pays 100% (Skilled) | Medicaid pays $209.50/day coinsurance | Medicaid pays up to 100% (patient liability applies) |
| Medicare with Employer-Sponsored Retiree Health Coverage | Medicare pays 100% (Skilled) | Plan may pay all/part of $209.50/day (varies by plan) | Private pay |
| Medicare Advantage Plan | Medicare pays 100% (via MA plan) | Member cost-share varies by plan (coinsurance rules differ) | Private pay |
| Medicare Advantage + Employer-Sponsored Retiree Coverage | Medicare pays 100% (via MA plan) | Who pays & amount vary by both plans | Private pay |
| Medicare Advantage with Medicaid | Medicare pays 100% (via MA plan) | Medicaid typically covers MA coinsurance | Medicaid pays up to 100% (patient liability applies) |
| Medicaid (no Medicare) | Medicaid pays up to 100% (patient liability applies) | Medicaid pays up to 100% (patient liability applies) | Medicaid pays up to 100% (patient liability applies) |
*Most Medigap plans cover 100% of the skilled nursing coinsurance, but confirm your plan’s benefits.
What does Medicare Part A actually cover—and for how long?
Medicare Part A covers up to 100 days of skilled nursing facility (SNF) care per benefit period, if eligibility rules are met. It pays 100% for Days 1–20 and requires a $209.50/day (2025) coinsurance on Days 21–100. After Day 100, Medicare coverage stops.
How do the Part A payment tiers break down?
| Days 1–20 | Days 21–100 | After 100 Days |
|---|---|---|
| Medicare pays 100% | Beneficiary pays $209.50/day coinsurance | Beneficiary pays 100% (no Medicare) |
What are the eligibility requirements for Medicare SNF coverage?
- Enrolled in Medicare Part A.
- 3-day inpatient hospital stay (admit day counts; ER/observation and discharge day do not).
- SNF admission within 30 days of the qualifying stay for the same (or related) condition.
- Physician certifies a daily need for skilled care in a Medicare-certified SNF.
What is the “3-day qualifying hospital stay” rule—and how is it miscounted?
You need three consecutive inpatient midnights. ER time, observation status, and the discharge day don’t count. Miscounting these days is a common reason for denials.
How does Medicaid differ—does it cover long-term custodial nursing home care?
Yes. Unlike Medicare, Medicaid can cover long-term custodial nursing home care (help with ADLs) indefinitely, so long as you continue to meet the financial limits and the Nursing Facility Level of Care (NFLOC).
How does Medicaid’s payment look over time?
| Days 1–20 | Days 21–100 | After 100 Days |
|---|---|---|
| Medicaid pays up to 100% (patient liability applies) | Medicaid pays up to 100% (patient liability applies) | Medicaid pays up to 100% (patient liability applies) |
What does it take to qualify for Medicaid nursing home coverage?
- Financial limits: In 2025, many states use about $2,901/mo income and $2,000 in countable assets for a single applicant (state rules vary).
- Medical need: Must meet the state’s Nursing Facility Level of Care (NFLOC).
- Facility: Must reside in a Medicaid-certified nursing home.
Over the limits? There are lawful planning options (e.g., Miller Trusts in income-cap states, spend-down strategies) that can help you qualify.
How do Medicare Advantage plans handle skilled nursing coverage?
Medicare Advantage (MA) plans must cover SNF care at least as well as Original Medicare, but cost-sharing varies by plan. Many MA plans have different daily copays and authorization rules.
What’s the Medicare Advantage payment pattern?
| Days 1–20 | Days 21–100 | After 100 Days |
|---|---|---|
| Covered (via MA plan) | Member cost-share varies by plan (not always $209.50) | Beneficiary pays 100% (no MA coverage) |
Who qualifies for a Medicare Advantage plan?
- Must have Medicare Part A and Part B.
- Must live in the plan’s service area.
Premiums, copays, and rules differ—use Medicare’s plan finder to compare.
Can supplement insurance help with Medicare’s skilled nursing coinsurance?
Yes. Medigap (with Original Medicare) and some employer-sponsored retiree plans can cover some or all of the $209.50/day coinsurance on Days 21–100. If you’re in a Medicare Advantage plan, Medigap can’t be purchased, and your cost-share depends on your MA plan.
How do supplement plans fit into the payment timeline?
| Days 1–20 | Days 21–100 | After 100 Days |
|---|---|---|
| Medicare pays (Original) or MA plan pays | Medigap/retiree plan may pay coinsurance (varies by plan) | Beneficiary pays 100% (unless Medicaid) |
Who can buy a Medigap plan?
- Must have Medicare Part A and Part B.
- Must live in the state where the plan is offered.
- Best time to enroll: 6-month Medigap open enrollment starting the month Part B begins at/after age 65—no health underwriting.
Do Medicare beneficiaries have to pay the SNF coinsurance out of pocket?
Not always. Many with Medigap, retiree coverage, or Medicaid won’t pay the full $209.50/day. Medicare Advantage members’ costs depend on their plan’s SNF cost-share rules.
What if you don’t have a supplement plan for the coinsurance?
You may need to pay out of pocket, unless you have long-term care insurance (which is usually purchased years earlier) or you qualify for Medicaid. If you’re likely to need longer-term care, apply for Medicaid as soon as appropriate.
How do you appeal if Medicare SNF coverage is ending?
What if the facility says skilled care is no longer needed?
You should receive a Notice of Medicare Non-Coverage (NOMNC) at least two days before coverage ends. If you disagree, file an expedited appeal with the QIO immediately (instructions on the notice). You cannot be discharged while the appeal is pending. If denied, you’re responsible for costs after coverage ends (but you can pursue further appeals).
What if you’ve simply used all 100 covered days?
There’s no appeal—Medicare coverage is exhausted. The facility will begin charging for any additional days. Consider Medicaid if long-term care is needed.
Medicare will no longer pay, but nursing home care is still needed—what now?
- Private pay (often unsustainable long-term for many families).
- Long-term care insurance (if already in place).
- Medicaid (apply if you meet—or can plan to meet—financial/medical rules). While your Medicaid application is pending, the facility generally cannot discharge you. If approved, Medicaid can cover from the application date and may cover up to 3 months retroactively if you qualified then.
Do you have to change facilities when switching from Medicare to Medicaid?
Usually, no. Most facilities that accept Medicare also accept Medicaid, and many provide both short-term SNF and long-term nursing home care. Confirm Medicaid bed availability with the facility.
