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What Happens When Medicare Stops Paying for Nursing Home Care?
Date Updated: December 23, 2024
Written by:
Sarah has produced thousands of articles in diverse niches over her decade-long career as a full-time freelance writer. This includes substantial content in the fields of senior care and health care. She has experience writing about wide-ranging topics, such as types of care, care costs, funding options, state Medicaid programs and senior resources.
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Gene Altaffer has a Masters in Gerontology from the University of Southern California and has worked in many avenues along the continuum of long-term care, assisting thousands of clients and their families since 1995. He also sold long-term care insurance from numerous carriers while also assisting families with retirement planning. Gene helps seniors navigate their Medicare plans, ensuring they understand their benefits and options.
When Medicare stops paying for nursing home care, individuals must find other ways to pay, including private and public funding, or find a different type of care setting. Other care settings often offer greater affordability, especially if physicians no longer deem skilled medical services as essential.
Medicare Coverage of Nursing Home Care
Medicare only covers short-term, medically necessary nursing home stays. Notably, it doesn’t pay for personal care alone; it only covers such support if seniors require skilled nursing care. Additionally, individuals must reside in Medicare-certified facilities. To qualify, seniors must be enrolled in Medicare Part A and start receiving physician-ordered care within 30 days of being discharged from a hospital. Moreover, their inpatient stay must have lasted for at least three consecutive days, including the admission day but excluding the discharge day.
The federal insurance plan pays daily rates and only covers full nursing home costs for the first 20 days of admission. After that, it pays partial costs for up to 100 days per benefit period. However, Medigap supplements may cover copayments between days 21 and 100. Coverage ends after 100 days.
Other Ways to Pay for Nursing Home Care
Several funding options exist for nursing facility care after Medicare ends. Medicaid pays full costs, including bed and board, for eligible seniors. However, supplemental charges may apply for nonessential services, such as comfort items. Qualification criteria include physician-certified medical need and income and asset limits. Seniors must also live in Medicaid-certified facilities since Medicaid pays for medically essential nursing home care indefinitely.
Veterans may qualify for VA programs and benefits that provide or pay for nursing home care. Existing policyholders can typically claim on their long-term care insurance policies, and many private life insurance policies allow for early payouts. Some older adults pay out of pocket for nursing home care, using income and savings. However, the high costs of nursing home care make this impossible for many; nationally, the median monthly cost in 2024 stands at $8,669 for a semi-private room and $9,733 for a private room.
Alternative Care Types
Seniors usually find other care settings more appropriate and affordable if they don't need intensive medical attention. For example, those who require only personal care assistance pay around $5,350 per month nationwide for assisted living. Moreover, they may qualify for financial aid via Medicaid waivers. Alternatively, older adults with continuing medical needs might safely transition back home with visiting support from home health care aides. Across the United States, agencies charge about $6,292 monthly, but seniors may qualify for public funding.