Does Medicare Cover Nursing Homes
by Christian Worstell | Published December 16, 2020 | Reviewed by John Krahnert
Medicare Part A covers limited skilled nursing care, as long as it is medically necessary to treat an injury or illness and you meet certain conditions. Medicare does not cover long-term care or custodial care, if that is the only care you require.
If you receive care in a skilled nursing facility, you will typically face certain out-of-pocket Medicare costs.
A Medicare Supplement plan can help pay for your skilled nursing facility care costs, such as Medicare deductibles and coinsurance.
When You Need Part
Updated By Bethany K. Laurence, Attorney
Progressive health care professionals often encourage people to get out of hospitals and nursing facilities and into their own or family members’ homes while recovering from injury or illness. With less honorable motives, insurance companies also pressure hospitals to release patients earlier so that if they continue to receive care, it will be a less costly variety at home.
In response to both these movements, many new home health care agencies have sprung up. You’re increasingly likely to find such an agency in your local area. Most are able to provide care for patients who no longer need high-level care in a hospital but who still require part-time nursing or rehabilitative therapy.
Does Medicare Pay For Home Health Care
There is an important distinction between medically necessary home health care and personal care services provided by an unskilled caregiver. Understanding the difference between these two levels of care is key to determining who is eligible for Medicare-covered in-home services. For more information on this topic, read The Difference Between Home Health Care and Non-Medical Home Care Services.
Only home health care services prescribed by a doctor and provided by skilled caregivers are covered by Medicare, but patients must meet specific eligibility requirements.
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Custodial Care Vs Skilled Nursing Facility Care
Custodial care is non-medical assistance with daily activities such as bathing, dressing, eating and using the restroom. Custodial care can occur at a person’s home or in a nursing or assisted living facility.
Although Medicare does not cover custodial care, it does cover some skilled nursing services , including:
-
Semi-private rooms
Medicare Part A also covers intermittent skilled nursing care at home, but it is restrictive.
What Home Health Care Will Aetna Medicare Advantage Plans Pay For
Medicare Advantage plans are required by law to include all benefits that are found in Original Medicare , which means any Medicare Advantage plan offered by Aetna will come with at least the following home health care coverage:
For certain home health care services, Medicare requires a beneficiary to be certified as home-bound by a doctor and under the coordinated care of a doctor or home health services team. While Aetna Medicare Advantage plans will provide coverage for each of the home health care services listed above, a Medicare Advantage plan can have differing eligibility rules and other conditions.
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Long Term Care Benefits
Medicare is the primary medical care insurance for a large number of seniors. Many are shocked to discover that Original Medicare , also called Traditional Medicare, does not cover costs for most types of long term care, including Alzheimers and dementia care. When it does pay, it is only in a very limited capacity. While Traditional Medicare is not a long term care solution, there are benefits for seniors with recoverable conditions on a short term basis. Also, as mentioned previously, some Medicare Advantage Plans now offer some home and community based long term care benefits under specific circumstances.
Skilled Nursing FacilitiesMedicare will pay for 100% of the cost of care up to 20 days at a skilled nursing facility and approximately 80% of the cost up to 80 more days. The care must be for recovery following an inpatient hospital stay.
Assisted Living CommunitiesMedicare does not cover any cost of assisted living. It will pay for most medical costs incurred while the senior is in assisted living, but will pay nothing toward custodial care or the room and board cost of assisted living. Some Medicare Advantage plans may pay for personal care assistance for persons residing in assisted living or memory care, but will not contribute towards the cost of room and board.
Adult Day CareOriginal Medicare does not pay for adult day care services, but some Medicare Advantage plans may cover the cost.
Does Medicare Advantage Cover Long
Medicare does not cover the cost for long-term assisted living facilities. But some Medicare Advantage plans, also known as Medicare Part C, pay for several related services.
More than 22 million Americans are already enrolled in Medicare Advantage and there are now more than 3,100 plans available nationwide.1
Families, social workers, doctors, and other healthcare workers can help figure out the best care arrangement for you or your loved ones. We can help you understand your options and get you started on the path to enrolling in a Medicare Advantage plan.2
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Medicare Coverage Of Nursing Home Care
One of the biggest misconceptions about Medicare is that it provides long-term nursing home coverage. It doesnt.
Medicare covers only limited periods of inpatient care, only in a skilled nursing or rehabilitation facility following a hospital stay, and only under strict guidelines. Still, Medicare nursing home coverage can be vital if the person youre caring for has just been hospitalized. Medicare can pay for costly short-term, intensive rehabilitation, which in turn can give you a chance to arrange for longer-term care if its needed.
What About Part D Medications
Medicare Part D is prescription drug coverage that helps pay for all or a portion of a persons medications.
If a person lives in a nursing home, theyll typically receive their prescriptions from a long-term care pharmacy that provides medications to those in long-term care facilities like a nursing home.
However, if youre in a skilled facility receiving skilled nursing care, Medicare Part A will usually cover your prescriptions during this time.
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What Nursing Home Benefits Are Available From The Va
The Department of Veterans Affairs provides long-term nursing home care through different types of facilities. There are the VAs own nursing homes, and there are private nursing homes that contract with the VA to care for veterans when no nearby VA facility is available. There are also the VAs Community Living Centers, which provide short-term residential care along with ongoing outpatient care. And the VA pays a small part of the cost of residence in State Veterans Homes for some veterans who are not eligible for direct VA nursing home care.
Eligible veterans may qualify for residence in a VA nursing home if they have physical and/or mental impairment serious enough to require nursing home care. If there is no VA nursing home close to the veterans home and family, or there are no available spaces in a nearby VA nursing home, the VA may pay for a veteran to reside in a nearby private nursing home if that facility has a contract with the VA to provide care to veterans.
Community Living Centers are another type of VA long-term care facility. They provide a combination of short-term residential care options similar to assisted living and ongoing community care to veterans with chronic, but stable conditions, including:
- Dementia or Alzheimers disease
- Conditions requiring rehabilitation or short-term special services such as respite or intravenous therapy
- Conditions requiring hospice or other palliative care at the end of life
Nursing Home Costs And Ways To Pay
The cost of nursing home care in the U.S is prohibitive for many, and it can vary widely between regions and states, from around $5,000 per month up to a surreal $25,000 per month. How much a nursing home charges depends on its geographic location, staffing levels, the complexity of care offered and the facilitys size and quality. Additionally, there may be à la carte costs to contend with. For example, a facility that offers social services like financial management aid is likely to charge extra for that feature, among others.
Nursing home prices can make it tempting to look for less costly, less supportive residential care options such as assisted living. However, nursing homes should never be conflated with assisted living facilities. Knowing the difference between the two is an important part of making sure you or someone you are responsible for is getting a sufficient level of aid and supervision.
While assisted living offers minor assistance with personal care as well as social and health-related community functions, what makes a nursing home different from other elder care choices is that residents are under the 24-hour supervision of licensed or registered nursing staff or of certified nursing assistants .
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To What Extent Will Medicare Cover Long
Like many Americans, when the need for long-term care first struck my family, we were fairly ignorant about the subject and especially the part about how to pay for it. We mistakenly assumed Medicare would pay for all of my grandmothers care needs.
In the end, our familys solution felt like putting together a puzzle. We relied upon multiple family members, respite care providers and home care professionals to provide my grandmother the care she required.
Does Medicare Advantage Cover In
Switching to a Medicare Advantage plan means you may be able to get coverage for some in-home services and possibly lower your out-of-pocket costs.
The additional coverage options, restrictions and out-of-pocket costs may vary from plan to plan, and not every plan covers in-home support services. Some plans require you to get prior authorization from your doctor for in-home services while others may require that your care come from an agency that contracts with your specific plan.
These supplemental benefits that are offered only through Medicare Advantage focus on your physical and emotional well-being, safety and your quality of life.6
Home Safety Improvements
Medicare Advantage plans now have the option of covering certain improvements to make your home safer and easier to navigate. These improvements include installation of shower grips and toilet rails, wheelchair ramps and wider door openings.
You may also qualify for additional home services, such as carpet cleaning and the installation of air purifiers to prevent allergy and asthma attacks.
Personal Care Services
More and more healthcare professionals recognize that quality of life is an important factor in your physical, mental and emotional well-being. Medicare Advantage plans now have the option of offering a host of personal care services to improve your quality of life. These services can include assistance with bathing, dressing and oral hygiene.
Transportation
Nutrition
Adult Day Care
Telehealth
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Depending On Your Needs Your Care Plan May Include:
- What kind of personal or health care services you need
- What type of staff should give you these services
- How often you need the services
- What kind of equipment or supplies you need
- What kind of diet you need and your food preferences
- How your care plan will help you reach your goals
- Information on whether you plan on returning to the community and, if so, a plan to help you meet that goal
Does Medicare Cover Durable Medical Equipment
Medicare will cover the cost of medically necessary equipment prescribed by a doctor for in-home use. This includes items such as canes or walkers, wheelchairs, blood sugar monitors, nebulizers, oxygen, and hospital beds. Patients typically pay 20 percent of the Medicare-approved amount for such equipment, as well as any remaining deductible under Part B.
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Does Medicare Cover Home Health Care For Dementia Patients
Dementia is not a specific disease but a general term for the impaired ability to remember, think, or make decisions that interferes with everyday activities, according to the Centers for Disease Control and Prevention . The Alzheimerâs Association reports that approximately 6.2 million people in the United States are currently living with some form of dementia, and Medicare can be a financial resource for those who have been diagnosed.
Whats The Difference Between Nursing Home Care Long
Its important to understand the different types or nursing care Medicare may cover, as well as the ones it doesnt, so you arent unexpectedly stuck paying your nursing home costs.
Nursing home care can be either skilled or custodial. Skilled nursing home care covered by Medicare is short-term and expected to help improve your condition. If you have hip replacement, for example, your doctor may recommend a couple of weeks in a skilled nursing facility for physical therapy to help you learn to walk with your new hip and recover your mobility more quickly.
Long-term care, on the other hand, is generally custodial carehelp with things such as eating, bathing, toileting, and dressing. As the name suggests, it may last a period of weeks, months, or years. It is usually not covered by Medicare.
Home care nursing is generally home health care provided by a credentialed medical professional. It can be short-term while you recover from an illness or injury, or long-term if you have a serious chronic condition or have chosen hospice care. Medicare may cover home care nursing under certain situations.
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Private Pay For Home Health Care Services
Private pay may be an option if you need home health care services but dont qualify for a government insurance program, if you dont have private insurance, or if you desire more services than these programs cover.
For several reasons, many seniors and their families choose to pay out-of-pocket for private care:
- Paying out-of-pocket gives you greater flexibility in the type and amount of services you order.
- In some cases, a patients Medicare coverage or other private insurance coverage may not pay for all of the home health care services needed or wanted.
- It may be that the benefits have been exhausted, or perhaps the patients medical needs do not qualify them for covered home care services.
What Is A Nursing Home
A nursing home is a place where a person can receive extra care services from nurses or nurses aides.
Many of these facilities may be homes or apartments for people who need extra care for their daily activities or who no longer desire to live alone. Some resemble hospitals or hotels with rooms with beds and baths and common spaces for classes, recreation, eating, and relaxing.
Most nursing homes provide around-the-clock care. Services can vary, but may include help to go to the bathroom, assistance getting medications, and meal services.
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What Types Of Care Does Medicare Cover
- Skilled nursing care. Medicare helps to pay for your recovery in a skilled nursing care facility after a three-day hospital stay. Medicare will cover the total cost of skilled nursing care for the first 20 days, after which youll pay $185.50 coinsurance per day . After 100 days, Medicare will stop paying.
- Home health care. If you are homebound by an illness or injury, and your doctor says you need short-term skilled care, Medicare will pay for nurses and therapists to provide services in your home. This is not round-the-clock care. Generally, it’s for no more than 28 hours per week. With your doctor’s recommendation, you may qualify for more.
- Hospice. Medicare covers hospice care. Hospice is care you get to make you more comfortable when you are in the last stage of life with a terminal illness. You’re eligible if you are not being treated for your terminal illness, and your doctor certifies that you probably will live no longer than six months. You can get care for longer than that, as long as your doctor says you are still terminally ill.
Do Advantage Plans Cover Any Part Of It
Medicare Advantage plans dont usually cover nursing home care thats considered custodial care. A few exceptions exist, including if a persons plan has a contract with a specific nursing home or organization that operates nursing homes.
Always contact your plan provider before going to a particular nursing home so you understand what services are and arent covered under your Medicare Advantage plan.
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Does Medicaid Cover The Costs Of A Nursing Home
As people age, the probability that they will need long-term care in a nursing home increase. Most Americans over the age of 65 rely on Medicare insurance to cover their health care costs. Unfortunately, Medicare coverage does not extend to long-term nursing home care and many people find themselves paying out-of-pocket.
If you or a loved one are Medicare recipients and facing the possibility of needing nursing home care, it is important to know all your insurance options ahead of time. If you do not have the financial means to pay out-of-pocket for nursing home care after your Medicare coverage ends, you may be able to get help from Medicaid.
Medicare Coverage for Nursing Home CareMedicare recipients have coverage for skilled nursing care lasting up to 100 days for every separate instance of an illness or injury. In order to be eligible for coverage, you must stay in a Medicare-approved facility, you must be admitted within 30 days of a hospital stay which lasted for three days or more, and you must have an order from a physician stating that you require treatment. The physician must certify that you need skilled nursing care to maintain or to slow the deterioration of your current status of health.
Medicare covers the cost of skilled nursing care, rehabilitative services, a semi-private room and meals, plus any medical supplies needed for treating your prescribed condition. It does not cover the cost of custodial care like bathing, feeding, or dressing.
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