Nursing home care can become a necessity if you or a loved one faces certain health challenges. Whether it’s recovering from a serious illness or injury, managing chronic conditions, or simply needing additional support with daily activities, nursing home care can play a vital role in the recuperation process.
For many seniors in nursing homes, Medicare can be a lifeline to cover some of the healthcare services. Unfortunately, it only offers limited coverage. So, what happens when Medicare stops paying for nursing home care? Let’s find out.
Key Takeaways
- Medicare Part A covers skilled nursing care for up to 100 days, with the costs increasing after the first 20 days and ending entirely after the 100th day.
- You may have other payment options including Medicaid, long-term care insurance, at-home care, and nonprofit care facilities.
- You can appeal your case with Medicare for a shot at an extension after the 100 days of coverage.
Medicare Coverage for Nursing Home Care
Before we proceed, you must understand that although nursing home care and skilled nursing care are often used interchangeably, there are differences.
- Most nursing homes provide long-term residential care for seniors who need assistance with daily living such as bathing, eating, and medication management.
- On the contrary, skilled nursing facilities (SNF) offer short-term care to individuals recovering from an illness/injury. Their services include specialized medical services and therapies, such as physical therapy and occupational therapy, to help patients get better and regain their independence.
With the differences explained, it’s clear that Original Medicare (Medicare Part A and Part B) doesn’t provide any coverage for basic nursing home care. If you’re on a Medicare Advantage Plan or other Medicare health plan, you may have different coverage so you will need to call your plan provider to enquire about any nursing home care coverage available.
Medicare Part A covers skilled nursing care under certain conditions for a limited period. Here’s an overview of your costs in Original Medicare for skilled nursing care:
- You don’t pay anything for the first 20 days
- After the first 20 days, you pay $200 daily up until the 100th day of SNF care
Unfortunately, Medicare will only cover you for 100 days of SNF care. What happens when Medicare stops paying for nursing home care? Unfortunately, after the 100th day, you pay all costs out-of-pocket.
What Happens when Medicare Stops Paying for Nursing Home Care?
There are other options to explore when Medicare stops paying for nursing home care. Depending on your situation, here are some options to check out:
Medicaid
Medicaid is an option to try when you meet the eligibility criteria. Generally, Medicaid is open to low-income individuals. You’ll also need to meet certain care requirements to get coverage for your nursing home care.
There’s something called the Nursing Home Level of Care (NHLOC), a formal designation that is used to determine if a person is eligible for Medicaid nursing home coverage. This NHLOC varies from state to state, so you need to find out what the rules are for your state of residence.
When you’re eligible, Medicaid pays for all the costs of living in a nursing home, like your room, food, and things you need for your health. There’s a catch though, you have to use all your money to help pay for it. They call it “Patient Liability.”
For example, if you receive income from sources like Social Security or pensions, you may use a major chunk of that income to cover the costs of your nursing home stay. This includes expenses such as room and board, meals, and medical supplies. The portion of your income you’re required to contribute towards these costs is known as patient liability.
Private Insurance
Another option is to buy long-term care (LTC) insurance to help cover the cost of nursing home care. To weigh this option, you need to be informed of all it entails. So, here are some things to note about this option:
- The monthly payments (premium) for LTC can be expensive and might not be affordable for everyone.
- In some cases, the premium becomes more expensive the older and sicker a person gets.
- Some insurance companies won’t give you coverage if you have certain health problems (be sure to contact your provider first).
- LTC insurance providers usually pay out when something happens that requires nursing home care or long-term care at home. However, the amount of money you get for coverage depends on your specific plan.
- The insurance might not cover all the costs and the payments might only last for a limited time.
At-Home Care
At-home care is a relatively cheaper alternative when you have support from your family and friends. It involves staying at home and receiving help from the people around you. Other than having a support network, this option is only feasible if your doctor certifies that you can receive care at your house.
If you need some medical services while at home, Medicare can help cover some of it like physical therapy and help from a home health aide. However, they will not cover the costs of personal care. You can find more details on how Medicare can help you with home health care here.
Non-Profit Facilities
While there are a lot more nursing homes for profit, you might be able to find a nonprofit assisted living facility to continue your care when Medicare stops paying. Although they’re not free, you might be eligible for financial aid.
Note that not all nonprofit facilities offer financial aid, but you can ask every facility you visit to find out what financial relief options are available to you.
Appealing Your Case
If Medicare stops paying for nursing home care, you have the right to appeal your case. During your care at an SNF, you’ll get a notice called “Notice of Medicare Non-Coverage.”
You should get this at least two days before your coverage ends. If you don’t, request it because it explains how you can request a fast appeal. Generally, the notice tells you the following:
- The date your coverage ends
- Explains that you may take over payment for care after the due date
- Details on your right to request a detailed explanation regarding why your covered services are ending
- Information about your right to a fast appeal, as well as the process to reach the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your state to appeal your case
What Is the Cost of Nursing Home Care?
According to the National Council on Aging, nursing home care costs more than other senior living options. These costs vary depending on your location, level of care, and the amount of time you’re staying at the facility.
Based on a 2021 survey, the average monthly cost of nursing home care in the U.S. is $9,034 for a private room and $7,908 for a shared room. This adds up in a year and may not be a financially suitable option for you.
This necessitates financial help from insurance providers like Medicare and Medicaid, and some nonprofit facilities.
Relief Recap
When Medicare stops covering nursing home care, you have other options. These include Medicaid, private insurance, at-home care, and nonprofit facilities. But if you want to continue with Medicare, you can also appeal your case. Understanding costs and options for financing are relevant for continued care.
Faith Boluwatife
Faith is a passionate advocate for social change. She brings a unique blend of professional expertise and personal experience to the discourse on poverty. With a background in humanities and an advanced degree on public health, she has dedicated years to working directly with marginalized communities, both as a volunteer and a seasoned professional.