Medicare covers a range of health services to beneficiaries in any living situation. However, like most health insurance plans, Medicare doesn’t pay for long-term care costs of residency at an assisted living facility or day-to-day custodial care.
Under specific circumstances, if a beneficiary requires a short-term stay for inpatient care in a skilled nursing facility that’s not merely custodial or long-term care, it may be covered by Medicare.
When is care at a skilled nursing facility covered?
Original Medicare will cover a portion of stays for up to 100 days each benefit period at a skilled nursing facility if a doctor determines that you need specialized health services after a qualifying hospital stay. Assisted living facilities do not count as skilled nursing since intensive medical care are not provided by them.
In order for a hospital stay to be considered “qualifying” you must be formally admitted to hospital for three or more days. Neither time spent there under observation, nor as an outpatient before you are admitted count toward the three inpatient days.
The skilled nursing facility must be Medicare-care-certified, and a doctor must determine that you need the care.The condition that will be treated at the facility must be the reason you were admitted to hospital or it was developed as a result of your inpatient stay such as an infection acquired during your stay. Additionally, the care provided by the nursing facility must be considered medically necessary.
The care at the skilled nursing facility must begin within generally 30 days of leaving hospital. You do not need to have another 3-day qualifying hospital stay if you need to re-enter a skilled nursing care facility again within 30 days of stopping care or leaving the facility.
How much of the cost will Medicare cover for a stay at a skilled nursing facility?
Original Medicare will cover a portion of the costs for up to 100 days for treatment during a benefit period at a skilled nursing facility. The first 20 days in residential care are fully covered by Medicare. Any stays during the remaining 80 days per benefit period, you will be responsible for $194.50 per day in coinsurance. Starting at day 101 and beyond, all cost will be payable by you while you are receiving care at a skilled nursing facility.
The cost of care at nursing homes and assisted living facilities
The average cost of a nursing home stay in 2021 was just over $108,000 per year, slightly more than double that of an assisted living facility, $54,000 annually, according to a Genworth Cost of Care Survey.
The daily rate varies widely from state to state with one in Missouri costing $195 compared to $1,036 in Alaska. The difference between assisted living residencies is more moderate, $3,000 in Missouri per month versus $6,978 in the District of Columbia.