What Medicare and Nursing Homes Coverage Actually Includes and What It Doesn’t

Medicare covers nursing home care only under specific conditions, and most people are surprised to learn those conditions are quite limited. Original Medicare Part A pays for skilled nursing facility care after a hospital stay of at least three days. This coverage lasts up to 100 days per benefit period. It only applies when you need skilled nursing or physical therapy.

If you require long-term care for help with activities of daily living, Medicare won’t cover it. That’s where Medicaid and long-term care insurance come in, filling the gap Medicare leaves behind for custodial nursing home care.

Dumm Takeaways

• Medicare covers skilled nursing only after a three-day hospital stay, not long-term custodial care
• Coverage lasts maximum 100 days per benefit period with full coverage for first 20 days
• Daily coinsurance of $204 applies from day 21 through day 100 unless you have Medigap
• Observation status doesn’t count toward the three-day requirement and disqualifies you from coverage
• Medicare stops paying when skilled nursing is no longer needed, often before day 100
• Medicaid covers long-term care after meeting strict income and asset limits
• Five-year lookback period penalizes asset transfers made to qualify for Medicaid
• Missouri allows $60 monthly personal needs allowance while Arkansas provides $50
• Medicare Advantage plans cover same skilled nursing benefits as Original Medicare
• Home health care and hospice offer alternatives to nursing facilities under Medicare

Why Medicare Usually Won’t Pay for Your Nursing Home Stay?

The Difference Between Skilled Care and Custodial Care

Medicare Part A covers skilled nursing facility care, which means you need medical services from licensed nurses or therapists. Skilled care includes wound care, IV medications, physical therapy, occupational therapy, and speech therapy administered by trained professionals.

Custodial care, on the other hand, involves help with activities of daily living like bathing, dressing, eating, and using the bathroom. Most nursing home residents need custodial care, not skilled nursing, which explains why Medicare doesn’t cover their stay.

What Most People Get Wrong About Medicare Coverage

The biggest misconception is that Medicare and Medicare Advantage plans pay for long-term care in nursing facilities. They don’t. Medicare only covers short-term rehabilitation after a hospital stay, not ongoing custodial assistance. Many families assume their loved one’s nursing home costs are covered, only to receive shocking bills when they discover the truth.

When Medicare Actually Steps In

Medicare-certified facility coverage starts only after a hospital stay of at least three days. You must enter the skilled nursing facility within 30 days of discharge, and your doctor must certify you need daily skilled nursing or therapy. Coverage includes:

• Semi-private room and meals
• Skilled nursing and medical care
• Physical therapy, occupational therapy, and speech-language pathology
• Medical supplies and equipment
• Medications administered at the facility

After meeting these conditions, Medicare covers the first 20 days completely, then requires daily coinsurance through day 100.

How to Qualify for Medicare’s 100-Day Skilled Nursing Benefit?

Three-Day Hospital Stay Requirement

Original Medicare requires a minimum three-day inpatient hospital stay before covering skilled nursing facility care. The three days must be consecutive and include the day of admission but not the discharge day.

Observation status doesn’t count toward this requirement, even if you spend multiple nights in the hospital. Many patients discover too late that their hospital classified them as outpatients under observation, disqualifying them from Medicare skilled nursing facility coverage entirely.

Medical Necessity and Doctor Orders

Your physician must certify that you need daily skilled nursing or therapy services. A discharge planner typically coordinates with your doctor to document medical necessity in your care plans. The Medicare-certified facility must provide services you can’t safely receive at home, such as wound care, IV medications, or intensive physical therapy following surgery or serious illness.

Timing Rules You Can’t Afford to Miss

You must enter the skilled nursing facility within 30 days of hospital discharge. Missing this window means losing your Medicare benefit period coverage. Each benefit period begins when you enter the hospital and ends after 60 consecutive days without inpatient or SNF care.

What Counts as a Qualifying Hospital Stay

A Springfield, Missouri resident was hospitalized for pneumonia and spent four nights in the hospital. She assumed her stay qualified her for Medicare coverage at a local nursing facility.

However, hospital records showed she was under observation status for the first two nights, giving her only two qualifying inpatient days. Her family had to pay privately until they could appeal the observation designation, eventually getting it reclassified and securing Medicare coverage.

Breaking Down the Costs for Days 1 Through 100

The First 20 Days Are Fully Covered

Medicare Part A pays 100% of covered skilled nursing facility care for the first 20 days of your benefit period. You won’t owe copays or coinsurance during the initial three weeks if you meet all qualification requirements. The Medicare-certified facility receives full payment directly from Medicare for your room, meals, skilled nursing, and therapy services.

Daily Coinsurance from Day 21 to Day 100

Starting on day 21, you’ll pay a daily coinsurance amount for each additional day through day 100. In 2025, the coinsurance is $204 per day, totaling over $16,000 if you stay the full 80 days. Medicare Supplement Insurance Plans can cover part or all of the coinsurance, depending on your policy type.

What Happens After Day 100 Ends

After day 100 in a benefit period, Medicare stops paying for SNF care entirely. You become responsible for:

• Full daily room and board rates
• All nursing home care costs
• Medical care and therapy sessions
• Medications and medical supplies

Most families turn to Medicaid, long-term care insurance, or personal funds at the point when Medicare coverage ends.

How Medigap Plans Can Eliminate Your Out-of-Pocket Costs

Medicare Supplement Insurance Plans, particularly Plans F, G, and N, cover the skilled nursing coinsurance from days 21 through 100. Plan G is the most popular option for new Medicare beneficiaries, covering the full daily coinsurance amount and preventing unexpected healthcare services expenses.

Table: Medicare Skilled Nursing Facility Cost Breakdown

Coverage Period	Medicare Pays	Your Cost	Total Days	Potential Out-of-Pocket
Days 1-20	100% of covered services	$0 per day	20 days	$0
Days 21-100	All costs minus coinsurance	$204 per day	80 days	$16,320
Days 101+	$0 (no coverage)	100% of all costs	Unlimited	$8,000-$12,000+ monthly
With Medigap Plan G	Medicare + Medigap combined	$0 per day	100 days	$0

What Medicare Actually Pays For in a Skilled Nursing Facility

Medical Services and Treatments Covered

Medicare Part A covers skilled nursing services provided by registered nurses and licensed practical nurses. Covered medical care includes wound dressing changes, IV therapy, injections, tube feedings, and catheter care. Your semi-private room, meals, and routine medical social services also fall under Medicare coverage when medically necessary.

Physical Therapy, Occupational Therapy, and Rehabilitation

Specialized rehabilitative services form the backbone of most Medicare-covered stays.

• Physical therapy helps you regain mobility and strength after surgery or illness.
• Occupational therapy teaches you to perform activities of daily living safely and independently.
• Speech-language pathology treats swallowing disorders and communication problems.

Medicare covers these therapies when your doctor orders them and documents ongoing progress.

Medications and Medical Supplies

The facility provides medications administered during your stay at no additional cost under Medicare Part A. Medical supplies like bandages, syringes, and oxygen equipment are also covered. However, outpatient care medications you take home fall under Medicare Part B or Part D coverage.

What You’ll Still Have to Pay For

A Little Rock, Arkansas resident recovering from hip replacement surgery received 45 days of SNF care. Medicare paid for her physical therapy and nursing. Her family paid separately for her private room upgrade, which cost $85 daily.

They also paid for her personal toiletries, and phone service. They also purchased reading glasses and a walker for home use, neither covered by Medicare. Her family still had to pay for her personal items, phone charges, television, private room upgrades, and other non-covered services.

When Your Medicare Coverage Runs Out or Gets Denied

Why Medicare Stops Paying Before 100 Days?

Medicare coverage ends when you no longer need skilled nursing or therapy services, even if you haven’t reached day 100. Once you plateau in physical therapy or no longer require daily skilled care, Medicare determines you need only custodial care and stops payment. Most beneficiaries receive far fewer than 100 days of coverage because they transition to custodial needs.

Common Reasons for Coverage Denial

Staff at Medicare-certified facilities may decide you do not meet medical necessity requirements. Common denial reasons include:

• Lack of documented progress in therapy
• Services available through home health care
• No qualifying three-day hospital stay
• Admission more than 30 days after discharge
• Observation status instead of inpatient status

Private insurance companies that run Medicare Advantage plans may have stricter rules than Original Medicare. They use these rules when checking skilled nursing facility care claims.

How to Appeal a Medicare Decision

You have 60 days to appeal a coverage denial. Contact your state survey agency or Medicare directly to request reconsideration. Your doctor must provide documentation supporting continued medical necessity. A discharge planner can help gather required medical records and care plans for your appeal.

Your Options When Coverage Ends

After Medicare stops paying, you can apply for Medicaid nursing facility services, use long-term care insurance, pay privately, or explore home health agency services. Many families transition to intermittent home health services covered under Medicare Part B for ongoing medical care needs.

Switching from Medicare to Medicaid for Long-Term Care

How Medicaid Differs from Medicare for Nursing Homes

Medicaid nursing facility programs cover custodial long-term care that Medicare won’t pay for. State Medicaid programs fund ongoing assistance with activities of daily living, including bathing, dressing, eating, and toileting. Medicare provides only short-term skilled nursing following hospitalization, but Medicaid pays for indefinite nursing home stays once you meet income and asset tests.

Income and Asset Limits You Need to Know

Most states limit countable assets to $2,000 for single individuals seeking Medicaid nursing facility services. Income limits vary by state, with many using qualified income trusts when monthly income exceeds the threshold. Exempt assets typically include:

• Your primary residence (with equity limits)
• One vehicle
• Personal belongings and household items
• Burial plots and small life insurance policies

Asset transfers within five years of application face penalties that delay Medicaid eligibility.

Protecting Your Spouse’s Financial Security

The community spouse resource allowance lets your healthy spouse keep a portion of joint assets, typically between $30,828 and $154,140 in 2025. A married couple can protect additional income through spousal impoverishment protections, ensuring the at-home spouse maintains adequate living funds.

The Five-Year Lookback Period Explained

State survey agencies review all asset transfers made within five years before your Medicaid application. Gifts, property transfers, or selling assets below market value create penalty periods. Strategic planning before needing care helps families legally protect wealth for future generations.

Missouri-Specific Rules for Nursing Home Coverage

MO HealthNet Eligibility and Application Process

MO HealthNet, Missouri’s Medicaid program, covers long-term care for eligible residents. Single applicants must have assets below $2,000 and monthly income under $2,901 (2025 limits). The application process needs financial documents. These include bank statements, property deeds, and income proof.

A verification step and security check confirm identity and prevent fraud. Processing typically takes 45-90 days, though expedited reviews are available for immediate nursing facility services needs.

Personal Needs Allowance in Missouri

Missouri residents in nursing facilities keep $60 monthly as a personal needs allowance. Social security benefits and other income go toward nursing home costs, leaving residents with $60 for:

• Personal toiletries and grooming items
• Clothing and shoes
• Entertainment and activities
• Phone cards or communication services

Missouri Care Options and Home-Based Alternatives

MO HealthNet offers home and community-based services as alternatives to nursing facility placement. Programs include personal care assistance, adult day care, respite care, and home modifications. Many Missouri residents prefer staying home with intermittent home health services rather than entering a convalescent home.

Medicare-Certified Facilities in Missouri

Medicare’s Care Compare tool lists all Medicare-certified facilities in Missouri with star ratings, inspection results, and enforcement actions. The CMS location database shows quality measures, staffing levels, and health insurance acceptance. Missouri has over 500 certified nursing facilities across St. Louis, Kansas City, Springfield, and rural communities.

Arkansas-Specific Rules for Nursing Home Coverage

Arkansas Medicaid Nursing Home Program

Arkansas Medicaid pays for nursing facility services for residents who meet financial and medical eligibility rules. The admission process includes cognitive assessments and verification of the need for skilled nursing or custodial care.

Single applicants must have countable assets below $2,000 and meet income thresholds, though qualified income trusts help those with higher monthly income qualify. Arkansas processes applications within 45 days for standard cases and 10 days for emergency placements.

Personal Needs Allowance in Arkansas

Arkansas allows nursing home residents to keep $50 monthly from their income as a personal needs allowance. Social security payments and pensions are applied toward the cost of care, with $50 retained for personal expenses like clothing, toiletries, and entertainment.

Asset Protection Strategies for Arkansas Residents

Arkansas residents can protect assets through several legal strategies:

• Community spouse resource allowance for married couples
• Transferring the home to a disabled child or caregiver child
• Irrevocable trusts established outside the lookback period
• Spending down on exempt assets like home repairs or vehicle purchases

Payment options vary, and strategic planning before needing care helps families preserve wealth legally.

Medicare-Certified Facilities in Arkansas

Arkansas has about 230 nursing facilities certified by Medicare. The CMS location tool provides facility ratings, rights and protections information, life safety code compliance, and emergency preparedness survey results. Little Rock, Fort Smith, Fayetteville, and Jonesboro offer multiple certified options for skilled nursing facility care.

How to Choose a Medicare-Certified Nursing Home

Using Medicare’s Care Compare Tool

Medicare’s Care Compare database lets you search Medicare-certified facilities by location, compare star ratings, and review inspection reports. The tool shows staffing levels, quality measures, health inspections, and enforcement actions taken against facilities. You can filter results by specialized services like dementia care, hospice care, or cancer patients support.

Star Ratings and What They Really Mean

Medicare assigns one to five stars based on health inspections, staffing, and quality measures. Five-star facilities demonstrate superior care, but ratings don’t tell the complete story. Check the details behind the rating, including recent survey results and civil rights requirements compliance.

Questions to Ask During Your Facility Visit

Ask about nurse-to-resident ratios. Also ask about therapy availability, care plan customization, and admission process requirements. Request information about:

• Daily routines and activity schedules
• Meal quality and dietary accommodations
• Security protocols and visitor policies
• Staff turnover rates

Red Flags That Signal Poor Quality Care

Warning signs include bad smells, residents left alone, not enough staff, dirty places, and injuries without explanation. Check for recent enforcement actions, failed emergency preparedness surveys, or life safety code violations. Facilities with frequent complaints about rights and protections violations or difficulties with leaving a nursing home should be avoided.

Alternatives to Nursing Home Care That Medicare Covers

Home Health Care Services

Medicare Part A and Part B cover intermittent home health services when you’re homebound and need skilled nursing or therapy. A home health agency provides part-time skilled nursing, physical therapy, occupational therapy, and speech-language pathology in your home. Coverage includes medical social services and some medical supplies, but not 24-hour care or custodial assistance with activities of daily living.

Assisted Living and Medicare Coverage

Medicare doesn’t cover assisted living room and board costs. However, Medicare Part B pays for healthcare services you receive in assisted living facilities, including doctor visits and outpatient care.

Adult Day Care Programs

Adult day programs offer supervision and activities but receive no Medicare coverage unless they provide skilled medical care through a certified home health agency.

Hospice Care Options

Medicare covers hospice care for terminally ill patients with six months or less to live. Benefits include:

• Nursing and medical care
• Pain management medications
• Medical equipment and supplies
• Counseling and support services

Hospice allows patients to remain home or in a facility with comprehensive end-of-life care covered by Medicare Part A.

Frequently Asked Questions

1. Does Medicare cover nursing home care for Alzheimer’s or dementia patients?

Medicare covers skilled nursing facility care for dementia patients only after a qualifying hospital stay and when they need skilled services. Custodial dementia care requires Medicaid, long-term care insurance, or private payment.

2. Can I use Medicare Advantage (Medicare Part C) for nursing home coverage?

Yes, Medicare Part C plans must cover everything Original Medicare covers, including skilled nursing facility care. Some Medicare Advantage plans offer additional benefits like limited custodial care or extended coverage days.

3. What are Medicare Savings Programs and how do they help with nursing home costs?

Medicare Savings Programs help low-income beneficiaries pay Medicare premiums, deductibles, and coinsurance. Programs vary by state but can significantly reduce your out-of-pocket costs during skilled nursing facility stays.

4. Can I switch from one Medicare-certified nursing home to another?

Yes, you can transfer to another Medicare-certified facility if medically appropriate and beds are available. Your remaining Medicare coverage days transfer with you within the same benefit period.

Conclusion

Medicare’s nursing home coverage is limited, and waiting until you need care leaves your family scrambling for solutions. Start planning now by reviewing your coverage options, exploring Medicaid eligibility, and considering long-term care insurance. Book a free consultation with our estate planning team to create a personalized strategy that protects your assets and ensures quality care when you need it most.