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Does Medicare Pay for Nursing Home Care?

Medicare will cover some amount of skilled nursing home coverage for qualified patients. In order to qualify for the Skilled Nursing benefit you must have Medicare Part A, and you must have days remaining in a Part A benefit period. In addition, you must have a prior qualifying hospital stay. A qualifying hospital stay in this case refers to a 3-day inpatient stay, which includes three “midnights.”

The care that you receive in the skilled nursing home must be related to the care that you received during your inpatient hospital stay. Therefore, an individual cannot enter a skilled nursing home for treatment of a broken hip following a hospital stay for the treatment of pneumonia.

In addition, your doctor must require that you need daily skilled care that is provided by, or under the direct supervision of, skilled nursing home facility staff. It is important to note that even if you are in a skilled nursing facility temporarily and only for rehabilitation services, your care will be considered as daily care – as long as you are getting the therapy services every day that they are offered. Regardless of the care you are receiving in the skilled nursing home, however, the facility does have to be certified by Medicare in order for benefits to be payable.

When in a skilled nursing facility, Medicare covered services can include the following:

  • Semi-private room
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy (provided that this is required to meet your health needs)
  • Speech-language pathology services (also provided that this is required to meet your health needs)
  • Medications
  • Medical social services
  • Medical supplies and equipment used in the facility
  • Ambulance transportation (when other transportation endangers your health) to the nearest supplier of necessary services that are not available at the skilled nursing facility
  • Dietary counseling

When you are residing in the skilled nursing home facility, your costs will be as follows:

  • Days 1 through 20: $0
  • Days 21 through 100: $157.50 per day in co-insurance
  • Days 101 and thereafter: all costs

What Medicare does NOT cover

Medicare will not pay for long-term nursing home care  or when the only type of care that you need is custodial care such as assistance with dressing or bathing. In order to receive this type in a Skilled Nursing facility you will either need to pay out of pocket or use your Medicaid benefit if you qualify for Medicaid.

Filling in Medicare’s Nursing Home Coverage Gaps

In order to help with some of the out-of-pocket costs that are required by you – such as the $157.50 per day co-insurance expense – you may consider the purchase of a Medicare Supplement insurance policy.

Some of these plans will provide coverage for all or a portion of the Medicare skilled nursing facility care co-insurance that is required. For example, in 2015, Medicare Supplement Plans C, D, F, G, M and N cover 100% of this amount, while Plans K and L provide partial coverage for this cost.

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