Does Medicare Cover Nursing Homes?
October 09, 2023 / Nursing Home
As you or your loved ones age, there will likely come a time when specialized care and assistance in a nursing home are required to continue feeling safe and comfortable. This level of care can be costly, and one common question is whether Medicare, the federal health insurance program primarily for those aged 65 and older, covers nursing home stays. The team at Senior Care AZ, an Arizona senior placement agency, is breaking down the various aspects of Medicare coverage for nursing homes, including what services are covered, how to qualify, and which parts of Medicare are involved.
What Is Medicare?
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS). It primarily serves individuals who are aged 65 and older but can also cover younger individuals with certain disabilities. Medicare is divided into different parts, each covering specific healthcare services. Medicare generally will not cover the complete costs of a long-term nursing home stay, but in some situations it may cover the costs of short-term skilled nursing care required after an injury or illness. There are a number of factors that go into what will be covered by Medicare, including the care your loved one needs and the different types of Medicare plans your loved one may have.
How Much Does a Nursing Home Cost?
Nursing home costs can vary significantly based on location, the level of care needed, and whether the facility is private or semi-private. On average, the cost of a semi-private room in a nursing home can range from $6,000 to $8,000 per month. These costs can vary depending on the quality of care a facility offers, the length of a stay in the facility and any extra medical care or services your loved one may require while they are in the facility. These expenses can quickly deplete savings, making Medicare coverage and other payment options an important consideration for many.
Does Medicare Cover Nursing Home Stays?
Medicare provides some coverage for nursing home stays, but it’s essential to understand the limitations. Medicare does not cover long-term care in nursing homes. Instead, it primarily covers short-term stays for medically necessary services.
Nursing Home Services Covered by Medicare
Medicare Part A, the hospital insurance portion of Medicare, covers skilled nursing care on a short-term basis, usually for up to 100 days per benefit period. To qualify for this coverage, certain conditions must be met, including a prior hospital stay of at least three days and the services must be deemed medically necessary by a healthcare provider. The following services may be covered under Medicare Part A:
- Semi-private room and board
- Skilled nursing care
- Physical therapy, speech therapy, or occupational therapy
- Medical supplies and equipment
- Meals
- Hospice care in some situations
Nursing Home Services Not Covered by Medicare
Medicare does not cover long-term care in nursing homes when the primary need is custodial care (assistance with activities of daily living, such as bathing, dressing, and eating) rather than skilled nursing care. Additionally, it does not cover:
- Room and board for long-term stays
- Custodial care
- Most dental care
- Eye exams or eyeglasses
- Hearing aids
- Personal care items (toiletries, clothing, etc.)
- Services provided by non-skilled personnel.
- Most prescription drugs
Which Parts of Medicare Cover Nursing Homes?
Medicare consists of different parts, each covering specific healthcare services. Understanding which parts of Medicare are involved in nursing home coverage is essential. The different parts of Medicare are detailed below, but this can be complex, especially if your loved one is not able to provide guidance on their specific Medicare plan. Speaking with your local Medicare office can help you gain more information that will help you make an informed decision about nursing home costs as it relates to your loved ones Medicare coverage.
Medicare Part A
Medicare Part A primarily covers inpatient hospital care, skilled nursing facility care (on a short-term basis), home health care, and hospice care. For nursing home stays, Part A is the relevant component.
Medicare Part B
Medicare Part B is the medical insurance part of Medicare. It covers medically necessary services and preventive care. Part B does not generally cover long-term nursing home care but may cover some medical services provided within the nursing home or other outpatient medical services like healthcare provider visits at home or at a nursing home.
Medicare Advantage
Medicare Advantage plans, also known as Medicare Part C, offer an alternative to original Medicare. They cover services included in both Part A and Part B and may provide additional benefits not covered by traditional Medicare. Some Medicare Advantage plans offer coverage for long-term nursing home care. Medicare advantage plans use private insurance companies to supplement Medicare plans, and some may cover short term stays and may include some long-term nursing home care.
Medicare Part D [h3]
Medicare Part D is the prescription drug coverage component of Medicare. While it does not cover nursing home care directly, it helps cover the cost of prescription drugs, which can be a significant part of a nursing home resident’s overall healthcare expenses.
Medigap Supplement Plans
Medigap, or Medicare Supplement Insurance, helps cover costs that original Medicare does not, including certain skilled nursing care expenses. However, Medigap does not provide coverage for long-term nursing home care.
How to Qualify for Medicare Nursing Home Coverage
To qualify for Medicare coverage for skilled nursing care, the following criteria must be met:
- You must have Medicare Part A.
- You must have a qualifying hospital stay of at least three days.
- Your doctor must certify that you need skilled nursing care.
- The skilled nursing care must be related to the condition for which you were hospitalized.
In summary, Medicare covers nursing home stays for medically necessary, short-term skilled nursing care. For long-term care or custodial care, alternative financial solutions, such as long-term care insurance or Medicaid, may be necessary. Understanding the specific coverage options and qualifications can help individuals plan for their healthcare needs as they age.