QUICK LINKS:

• What is Medicare
• What are the different parts to Medicare
• Medicare Coverage for Nursing Home Care
• What Happens After Medicare Stops Paying 
• Medicaid Financial Assistance for Long Term Care  
• Skilled Nursing Homes A Continued Support System Beyond Medicare Coverage
• Alternatives to Medicare Coverage for Nursing Homes

Many assume that Medicare will cover the full cost of an extended stay in a nursing home, only to face the harsh reality that this coverage is limited. This common misconception can leave families unprepared for the financial and logistical challenges ahead.

Understanding your options and planning ahead can make all the difference in ensuring your loved one receives the care they need without unnecessary stress or financial strain.

So, what happens when Medicare stops paying for nursing home care?

What is Medicare

Growing older has its perks, and Medicare is one of them—think of it as the VIP health insurance program for those 65 and up. Medicare is a federal health insurance program in the United States designed primarily for individuals aged 65 and older, it also provides coverage for certain younger individuals with disabilities or specific health conditions, such as End-Stage Renal Disease (ESRD). It’s divided into four parts, each offering different types of coverage. Together, these parts aim to provide comprehensive healthcare options for eligible beneficiaries.

What are the different parts to Medicare

Understanding the various parts of Medicare is essential for making informed decisions about healthcare options, including nursing home care.

• Medicare Part A: This part provides coverage for hospital inpatient stays, skilled nursing facility care, hospice care, and some home health services. It ensures that individuals have access to necessary care when it comes to hospitalizations and specialized nursing facility services.
• Medicare Part B: Part B covers doctor visits, outpatient care, preventive services, and medical equipment. It ensures that individuals have access to essential medical services outside of a hospital setting, including regular check-ups, screenings, and necessary equipment.
• Medicare Part D: Part D focuses on prescription drug coverage. It helps individuals afford necessary medications by providing coverage for a wide range of prescription drugs. This part ensures that individuals have access to the medications they need to manage their health conditions.

By understanding the different parts of Medicare, individuals can navigate their healthcare needs more effectively and make informed decisions about the coverage options available to them. It’s important to review and evaluate the specific coverage provided by each part to ensure that healthcare needs, including nursing home care, are adequately addressed.

Medicare Coverage for Nursing Home Care 

Medicare coverage offers a broad range of healthcare benefits, but its support for nursing home care is limited. It generally covers only short-term stays in skilled nursing facilities, and even then, only under specific circumstances. For example, Medicare may pay for care if you are recovering from a hospital stay of at least three days and require specialized medical care such as physical therapy or wound treatment. However, Medicare does not cover long-term custodial care, which includes assistance with daily activities like bathing, dressing, or eating.

This distinction is crucial for individuals and families planning for healthcare needs in their later years, as they may need to explore alternative options like Medicaid, long-term care insurance, or personal savings to cover extended stays in nursing facilities. Understanding these limitations can help ensure proper preparation for future care needs.

When Does Medicare Cover Nursing Home Care?

Medicare Part A may cover short-term stays for rehabilitation following a hospital admission. If you or your loved one meets these conditions, Medicare will pay for up to 100 days in a skilled nursing facility (SNF): 

• You had an inpatient hospital stay of at least three consecutive days. 
• You need skilled nursing care, such as physical therapy or medication management, provided by licensed professionals. 
• A doctor certifies that you require daily skilled care. 
• The nursing home is Medicare-approved. 

Medicare Payment Breakdown 

• Days 1–20: Medicare pays 100% of the cost. 
• Days 21–100: You are responsible for a daily co-payment ($200 per day in 2023). Medicare pays the remainder. 
• After 100 days: Medicare stops covering your stay entirely. 

Once you or your loved one no longer qualifies for skilled nursing care, Medicare will not cover ongoing custodial care, which includes help with daily living tasks, such as bathing, dressing, or eating.

What Happens After Medicare Stops Paying

When Medicare’s coverage for nursing home care ends around day 101, families often face a financial and logistical conundrum.

Here’s what to do next..

If your loved one cannot afford to pay nursing home costs out-of-pocket, Medicaid becomes the primary option. Unlike Medicare, Medicaid covers long-term custodial care for individuals with low income and limited assets. 

Medicaid: Financial Assistance for Long-Term Care

Medicaid is a government program designed to provide financial assistance for long-term care to individuals with limited income and assets. Unlike Medicare, which has specific limitations on coverage for nursing home care, Medicaid steps in to cover the costs when Medicare’s coverage ends. It serves as a safety net for those who cannot afford to pay for nursing home costs out-of-pocket.

Understanding Medicaid’s Role

Medicaid eligibility requirements vary by state, but there are common criteria to consider. These include income limits, asset limits, and a spend-down process for those who exceed these limits. Medicaid sets income limits based on the federal poverty level, typically requiring monthly income to fall below a certain threshold.

Asset limits also exist, with states generally requiring assets to be below a specific amount, although certain exclusions may apply. It’s important to note that Medicaid considers different rules for assets, such as the exclusion of a primary residence.

Navigating the Medicaid application process and understanding the eligibility requirements can be complex.

Seeking guidance from professionals specializing in Medicaid planning can provide valuable assistance in ensuring that your loved one receives the necessary support for long-term care.

Key Medicaid Eligibility Requirements:

• Income Limits: These vary by state, but typically, monthly income must fall below the federal poverty level ($2,742 per month for nursing home care in most states in 2023). 
• Asset Limits: Many states require assets to be under $2,000 for an individual, although certain exclusions apply (e.g., a primary residence may not count). 
• Spend-Down Process: For those exceeding Medicaid income or asset limits, some states allow applicants to spend down their resources on qualifying medical or nursing home expenses to meet eligibility criteria. 

Skilled Nursing Homes: A Continued Support System Beyond Medicare Coverage

Once Medicare coverage for nursing home care concludes, skilled nursing homes come into play as a vital support system for individuals in need of ongoing specialized medical care. Skilled nursing homes provide a higher level of medical attention, rehabilitation therapy, and assistance with activities of daily living. These facilities have a team of skilled nurses, therapists, and caregivers who work together to provide round-the-clock care and support. 

Alternatives to Medicare Coverage for Nursing Homes

For those looking to limit or avoid traditional nursing home stays altogether, several alternatives exist:

Home Health Care 

For seniors who prefer to stay at home, home health care services provide skilled nursing, therapy, or personal care in the comfort of their residence. While Medicare may cover some home health services, ongoing custodial care is typically out-of-pocket. 

Assisted Living Facilities 

Unlike nursing homes, assisted living facilities offer less intensive care for individuals needing some help with daily activities. Prices are generally lower than nursing homes, although they are not covered by Medicare. Medicaid may cover costs in some states. 

Adult Day Care Programs 

Adult day care centers provide social interaction and care for seniors during the day while allowing them to return home at night. These programs are typically more affordable than full-time nursing home care. 

Family Caregiver Support 

For families willing to provide care themselves, programs such as Medicaid’s Home & Community-Based Services (HCBS) can offer financial assistance to qualified caregivers. 

What’s Next?

Navigating the complexities of nursing home care costs with careful planning and informed decision-making can ensure your loved one receives the quality care they deserve.

By assessing your loved one’s care needs, exploring Medicaid eligibility, and researching alternative options, you can make confident and proactive choices for their well-being. Remember, it’s never too early to start planning and seeking guidance from health insurance experts like Apollo Health Insurance who can provide valuable insights tailored to your specific situation.