Patient Liability: What You Pay the Nursing Home

Being approved for Long-Term Care Medicaid does not usually mean nursing home care becomes free. Most residents pay part of their own income to the nursing home each month, and Medicaid pays the rest. That monthly payment is called patient liability. States also call it the share of cost, patient pay amount, resident liability or, in New York, NAMI (net available monthly income). This guide explains how it is figured.

Figures change periodically. Double-check current amounts before relying on them.

The basic idea

After a person is approved, the state takes their gross monthly income and subtracts certain allowances required by federal law. What is left is the patient liability, which the resident pays to the nursing home. Medicaid pays the nursing home the difference between its Medicaid rate and the patient liability.

This calculation is called the post-eligibility treatment of income.

The deductions, in order

Federal law requires states to subtract these from the resident’s income:

1. Personal needs allowance for the resident. At least $30 under federal law; from $30 to $200 a month in 2026, depending on the state. See Personal needs allowance.
2. Community spouse monthly income allowance, if the resident has a spouse at home whose own income is below the minimum. In 2026 the minimum need is $2,705 a month (from July 1, 2026), with a maximum of $4,066.50. See MMMNA.
3. Family allowance for certain dependent family members who live with the spouse at home.
4. Incurred medical expenses not covered by Medicaid or other insurance, including health insurance premiums (such as Medicare Part B and D premiums and supplement premiums), and certain necessary medical costs.

Some states allow additional deductions, such as:

• a home maintenance allowance for a resident expected to return home within a short time (often six months), to keep up the home;
• guardianship fees, in some states;
• amounts paid into a Qualified Income Trust that are used for allowed purposes.

Worked example: single resident

Robert lives in a Medicaid nursing home in Pennsylvania. His gross income is $2,400 a month (Social Security and a small pension). He pays $202.90 for Medicare Part B and $60 for a Part D plan.

Robert pays $2,077.10 to the nursing home each month. Medicaid pays the rest of the nursing home’s Medicaid rate.

Worked example: married resident

Anna lives in a Medicaid nursing home in Texas. Her gross income is $2,600 a month. Her husband George lives at home with $1,100 a month of his own income. Texas uses the federal maximum for the spouse’s allowance ($4,066.50 in 2026), but the allowance is limited to what George needs to reach it and to Anna’s available income.

Here, nearly all of Anna’s income goes to George to bring his income up toward the allowed amount, and Medicaid pays the whole nursing home bill. If Anna had health insurance premiums, the order of deductions would affect how much reaches George.

The allowance only counts if it is actually paid to George each month.

When the patient liability is paid

Patient liability is usually due to the nursing home each month, often by the 10th. Families should:

• set up an automatic payment, or have the resident’s income deposited where the nursing home can be paid promptly;
• keep receipts;
• pay on time. Unpaid patient liability is one of the most common reasons nursing homes give notice of discharge.

Patient liability during the application

While an application is pending, the nursing home will usually ask the resident to pay their estimated patient liability each month. Once approved, the amount is finalized, and any overpayment is usually refunded or credited. Retroactive coverage may also apply. See How to apply.

Changes to patient liability

Patient liability changes when:

• Social Security increases each January (the cost-of-living adjustment);
• Medicare premiums change;
• the spouse at home’s income or housing costs change;
• the federal minimum spousal allowance changes each July 1;
• the resident’s income changes for any other reason.

The state sends a new notice when the amount changes. Families should report changes promptly, usually within 10 days.

Patient liability for home care

People on home care waivers may also pay a share of cost, but the rules are different. They usually keep a much larger allowance for living expenses, rent and food. Each state sets its own rules.

If you disagree with the amount

The notice that sets patient liability will explain how to ask for a fair hearing. Common issues include:

• health insurance premiums that were not subtracted;
• an incorrect allowance for the spouse at home;
• income counted twice.

A spouse at home can also ask for a higher allowance through a fair hearing in cases of exceptional financial hardship. See Raising the allowances through a fair hearing.

Because the allowances interact, mistakes in the calculation are not unusual. A Certified Medicaid Planner (CMP) can review the figures and help with a request for a hearing.

Common questions

Do I pay the nursing home’s private rate? No. You pay your patient liability, and Medicaid pays the rest.

What if my income goes up? Your patient liability usually goes up too.

What if I can’t pay? Talk to the nursing home’s business office right away. Unpaid patient liability can lead to discharge.

Step-by-step: figuring your own estimate

1. Start with gross monthly income for the resident: Social Security before the Medicare premium, pensions before withholding, and any other income.
2. Subtract the personal needs allowance for your state (see the chart).
3. If married, subtract the spouse at home’s allowance, if their income is below their MMMNA.
4. Subtract health insurance premiums: Medicare Part B (the 2026 standard premium is $202.90), Part D, and any supplement.
5. Subtract any other deductions your state allows, such as a home maintenance allowance.
6. What is left is the estimated patient liability.

The state’s figure is the one that counts, but an estimate helps families plan and spot mistakes.

Patient liability and Medicare

If the resident is in a nursing home for a short rehab stay covered by Medicare, Medicare pays in full for the first 20 days and partly for days 21 through 100, with a daily coinsurance. During that time, Medicaid may pay the coinsurance for people who qualify. Once Medicare coverage ends, the regular patient liability applies.

Patient liability for a partial month

When someone enters a nursing home partway through the month, or dies partway through, the patient liability for that month may be prorated or set by state rules. The resident’s income for that month may already have been spent on rent or other costs. Ask the nursing home and the caseworker how the first and last months are handled.

Records to keep

• Every notice from the state showing the patient liability amount.
• Receipts or bank records for each payment to the nursing home.
• Statements for health insurance premiums.
• Notices of Social Security and pension changes.
• For married couples, proof of the monthly transfer to the spouse at home.

Common misunderstandings

• “Medicaid takes all my income.” Not all of it. The personal needs allowance (federal law requires at least $30 a month, and many states use more), any spousal and family allowances, and allowed health insurance premiums are subtracted first.
• “The patient liability stays the same forever.” It changes when income changes, for example after an annual Social Security cost-of-living increase or a change in the Medicare Part B premium (the 2026 standard premium is $202.90 a month).
• “If I don’t pay, Medicaid will cover it.” The facility can pursue the unpaid amount and may begin a discharge process for nonpayment.
• “Medicaid pays the facility first, then I pay Medicaid.” The resident usually pays the patient liability to the facility, and Medicaid pays the facility the rest.

Veterans and the $90 pension

A veteran with no spouse or dependent child who is in a Medicaid-covered nursing facility has their VA pension reduced to $90 a month after the month of admission. Federal law says that $90 cannot be used to reduce what Medicaid pays the facility. In practice, it stays with the veteran. The same protection applies to a surviving spouse with no child. Whether the $90 is in addition to the state’s personal needs allowance depends on state rules. VA disability compensation is different from a VA pension and is generally counted as income.

Related guides

• Personal needs allowance
• Income for couples
• MMMNA
• What counts as income?
• State guides

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.