Does Medicare Cover Nursing Homes?Learn About Medicare’s Coverage for Nursing Homes.
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According to the Kaiser Family Foundation, in 2020 nearly 1.5 million people live in nursing homes or care facilities across the U.S..
If you’re considering moving into a nursing home or have a loved one that needs full-time care, it’s important to understand your costs.
This article explains Medicare coverage for nursing homes. It will also cover the costs of nursing homes and explore alternative ways to get coverage.
What Is Medicare?
Medicare is a U.S federal health insurance program for people 65 and older, some younger people with disabilities, as well as people with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (A.L.S).
The Different Parts of Medicare
Medicare is comprised of the following:
Medicare Part A, which refers to inpatient treatment and hospital care, including hospital stays, hospital treatments, and general nursing costs.
Medicare Part B, which relates to outpatient Medicare coverage and includes preventive treatments, doctors’ consultations, scans, and tests.
Medicare Part D, which refers to prescription drugs that are self-administered at home. This includes chronic heart medication, pain pills, and other ongoing medicines that people use.
What Is a Nursing Home?
A nursing home is the highest level of care for older adults outside of a hospital and provides what is called custodial care.
Nursing homes differ from other senior housing facilities in that they also provide a high-level of medical care as well.
A nursing home allows for the delivery of medical procedures and therapies on-site that would not be possible in other housing.
What Is Custodial Care?
Custodial care is nonmedical care that helps individuals with their activities of daily living (ADL), such as eating and bathing.
Custodial care for an individual is generally recommended by authorized medical personnel, but providers of custodial care are not required to be medical professionals.
There are five ADLs, namely:
Bathing: This includes personal hygiene and grooming.
Dressing: This includes dressing and undressing.
Transferring: This includes movement and mobility.
Toileting: This includes continence-related tasks, including control and hygiene.
Eating: This includes food preparation and feeding.
At a nursing home:
A licensed physician supervises each patient’s care.
A nurse or other medical professional is almost always on the premises.
Skilled nursing care is available on-site, usually 24 hours a day.
Other medical professionals, such as occupational or physical therapists, are also available when needed.
Access to supplies for medical treatments.
What Does Medicare Cover in Nursing Home Care?
As a general rule, if a person needs care that doesn’t require a qualified professional, Medicare doesn’t cover the service.
Medicare also won’t cover care in a nursing home when a person only needs custodial care. However, there are some things Medicare does cover, such as skilled nursing care in a nursing home facility.
Requirements for Medicare to Cover Care in a Nursing Home or Skilled Nursing Facility
The Centers for Medicare and Medicaid Services (CMS) will generally cover your skilled nursing care in the following circumstances:
✅ You have Medicare Part A and days left in your benefit period.
✅ You’ve had a qualifying hospital stay. A hospital stay is qualified if it was at least 3 consecutive calendar days.
✅ Your doctor has determined that you require daily, skilled nursing care.
✅ The care must be received at a skilled nursing facility.
✅ The skilled nursing facilities where you receive your services are Medicare-certified.
✅ You must require skilled services for a hospital-related medical condition or a condition that started while you were in a skilled nursing facility receiving treatment for the original, hospital-related medical condition.
What Is a Benefit Period?
A benefit period begins the day you're admitted as an inpatient in a hospital or skilled nursing facility.
Skilled Nursing Facilities: A place where people go when they require medical care in cases where, for example, they need to recover from a stroke.
The benefit period ends when you haven't received any inpatient hospital care or skilled care in a skilled nursing facility or hospital for 60 consecutive days.
If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins.
You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
Nursing Home Coverage Through Medicare Advantage Plans
If you or your loved one is on Medicare Advantage, they might be able to secure a nursing home care provider through their healthcare provider.
Many Medicare Advantage plans offer added benefits on top of what you’ll get through Original Medicare. Some of these include:
Home health care.
Coverage for certain over-the-counter medical supplies.
Prescription mailing services.
Skilled nursing care.
We advise you to check your Medicare Advantage plan to see what additional coverage benefits they offer. In some cases, your plan may cover skilled nursing and a part or all of your nursing home costs.
If your plan doesn't offer coverage for nursing home care, speak to an agent and consider switching to a plan that does.
If you are considering a nursing home for yourself or a family member, one type of private health care plan that provides nursing home benefits are SNPs (Special Needs Plans).
These are plans specifically designed to provide targeted care to special needs individuals, such as the elderly.
SNPs come in several forms, including:
Chronic Condition SNP (CC-SNPs): These are plans that cater to people with chronic conditions, such as heart disease and neurological disorders.
Institutional SNP (I-SNPs): These are plans specifically designed for people who need various forms of qualifying long-term care.
Dual-Eligible SNP (DE-SNPs): These are Medicare Advantage plans for people who qualify for Medicare and Medicaid.
What Is an I-SNP?
Institutional Special Needs Plans are limited to people eligible for Medicare Advantage plans who, for 90 days or longer, have had or are expected to need the level of services provided in:
A long-term care (LTC) skilled nursing facility.
An LTC nursing facility (NF).
An intermediate care facility for individuals with intellectual disabilities (ICF/IDD).
An inpatient psychiatric facility.
Before you start researching these plans, keep the following points in mind:
1) The availability of SNPs will vary based on your location. Some companies offer SNPs countrywide while others only offer them in certain counties.
2) One Medicare Advantage company could have multiple SNPs for you to choose from, while another may only provide a single plan.
3) An SNP that was available last year might not be available this year. This is because every insurance company that offers Medicare Advantage has the annual option to join or leave Medicare.
How Much Do Nursing Home Costs?
The cost of nursing home care depends on several factors, including:
The length of the person’s stay.
Any special considerations.
Many nursing home facilities have all-inclusive rates while others may charge additional fees for services beyond housing, food, and housecleaning.
Additionally, there will be a higher cost for a private room compared to a semi-private room, where residents have a roommate typically separated by a curtain between them.
According to a 2022 study by The World Population Review, here’s what you can expect to pay for nursing home services:
The average private room in a nursing home in the U.S. costs $8,365 per month or $275 per day.
The average cost of a semi-private room is $7,441 per month and $245 per day.
Annually, a semi-private room costs an average of $89,297 and a private room an average of $100,375.
Alternatives to Medicare for Nursing Home Care Coverage
Long-Term Care Insurance
This is an insurance policy that helps pay for the costs associated with long-term care. It generally covers care not provided by Medicare.
Long-term care insurance can pay for nursing home care if you can afford the premiums for years after retirement.
Medicare Terms You Should Know
Monthly premiums are fees that members of Part B, Part D drug plans, Medicare Advantage, or Medicare Supplement Plans pay.
Deductibles are amounts that people have to cover before their Medicare plan or insurance starts to pay for medical expenses.
This insurance can cover much of the expense of custodial care in:
Assisted living facilities.
Payout of Your Savings
If you have accumulated enough wealth, you may be able to pay roughly $100,000 out of your pocket annually for nursing home costs.
However, planning to pay for nursing home care means facing complex, unexpected, and sometimes huge costs, not to mention your own death.
Before you decided to take this route, it’s always wise to see if you can join an affordable Medicare Advantage plan that can help you pay for skilled nursing care or a nursing home.
Where Can I Learn More About Medicare?
If you are looking for accurate information about Original Medicare, Medicare Advantage Plans, or anything Medicare-related, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.