Do Medicare and Medicaid Pay for Nursing Homes?

Few Americans will be able to pay the estimated $100,000 annual cost of nursing homes out of their own pockets. Fortunately, numerous government initiatives can reduce these expenses.

Medicare and Medicaid can assist in defraying the expense of nursing home care in addition to financial resources like personal savings and VA benefits. When used together, these programs can frequently pay for the majority of your estimated expenses.

Just so you know, the price of nursing homes keeps rising quickly. Thankfully, there are ways to subsidize some of the expenses. Read our article on nursing home costs for additional information.

Does Medicare Pay for a Nursing Home?

Unfortunately, Original Medicare does not pay for long-term nursing home care; however, other Medicare benefits may cover “medically required” or “vital” nursing home care. Meal preparation, prescription medications, durable medical equipment, counseling, and other services are a few of them. Overall, Original Medicare does not cover long-term stays; only brief visits are covered.

Medicare Part A

Even though Original Medicare often doesn’t cover nursing facility costs, Part A could be able to help with some of the expenses. With the caveat of being neither long-term nor custodial, skilled nursing facility or nursing home care is normally covered by Medicare Part A (Hospital Insurance).

If a doctor determines that you need skilled nursing care, you can be eligible for coverage via Medicare Part A. Medicare claims that Medicare Part A can pay for some home healthcare services, skilled nursing facilities, hospice care, and inpatient hospital stays. Medicare Part A, for instance, may pay for medication management or wound care in an inpatient hospital environment. Prescription drugs, changing sterile dressings, nutrition-related services, and meals are some of the most frequent services that may be covered by Medicare Part A.

Medicare Part B

Medicare Part B can help pay for chiropractic therapy, oxygen tanks, and other durable medical equipment, even though it cannot fully cover the cost of nursing homes.

The majority of diagnostic and therapeutic services as well as outpatient hospital services like an ER visit or X-rays are covered by Part B or medical insurance. 80 percent of the cost of medically essential services will be covered by Medicare Part B, with the other 20 percent being your responsibility.

Pro Tip: If your oxygen levels are low, you may want to think about purchasing a portable oxygen concentrator. Check out our article on the top portable oxygen concentrators.

Medicare Advantage

Although Original Medicare still covers nursing homes, Medicare Advantage may offer additional coverage for other treatments relating to vision, hearing, or dental care. It may also include senior fitness programs. You might even be covered for things like doctor visits, over-the-counter medications, and transportation depending on your Medicare Advantage plan. To find out if nursing home care can be reimbursed, I’d suggest getting in touch with your specific Medicare Advantage plan.

Medicare Part D

If you require prescription prescriptions while residing in a nursing home, Medicare Part D, also known as Prescription Drug Coverage, may be able to assist with the expense. It can cover some medically necessary services but not nursing home charges. You must have either Medicare Part A or Part B to sign up for Medicare Part D.

Medigap

Some Medigap and Medicare Advantage plans function by filling in Original Medicare’s gaps. Medigap might pay for skilled nursing care. Find out what is covered by your Medigap coverage by checking. Normally, if you require a skilled nursing facility for more than 100 days, your Medigap insurance may be able to pay for the costs associated with it.

Read our article on Medigap vs. Medicaid to find out more information regarding Medicaid and Medigap coverage.

Does Medicaid Pay for a Nursing Home?

Depending on financial eligibility and if the service is judged medically essential, Medicaid may pay for nursing homes and cover some services. Medicaid, in contrast to Medicare, can cover both lodging and board for senior citizens staying in nursing homes for extended periods. Depending on the state in which you reside, Medicaid may cover all nursing home expenses, including any additional services needed.

To qualify for long-term care coverage at a nursing home or for medical treatments, a person would need to give Medicaid the majority of their current income, according to one of their conditions.

For instance, if your monthly income were $3,000, Medicaid would likely require you to forfeit $2,870 to continue covering the expense of a nursing facility. Medicaid does assist you in keeping a modest amount aside for your spending money. However, the majority of the money is used to use Medicaid to pay for your nursing home room and board.

How Much Will Medicaid Pay for Nursing Home Care?

Medicaid pays an average of 45 to 65 percent of the cost of nursing home care for those who qualify, covering the majority of the bill. However, several variables, including your financial situation, the state you live in, and the level of care required, greatly influence your coverage.

Depending on the demand for nursing home care coverage, Medicaid coverage amounts may vary from state to state. In Texas, the average cost of nursing home care is $165 per day, while California’s average cost is on the higher end at $304 per day. This has a significant impact on the Medicaid coverage and perks you can get to help with the expense of nursing home care.

Medicaid Eligibility for Nursing Home Care

Like many other financial assistance programs, Medicaid coverage is based on several variables, including age, financial situation, assets, and amount of care. Check to discover if you fulfill the Medicaid eligibility requirements in the state where you currently live if you require assistance for long-term nursing home care. Usually, one of the criteria for eligibility is that the cost of your nursing home must be covered by the majority of your income.

Financial Eligibility

You must fulfill certain income eligibility standards to be eligible for Medicaid. The criteria for financial eligibility may vary slightly depending on the state in which you live. For instance, in the state of California, a household’s income cannot be greater than $16,395 per year, or 138 percent of the federal poverty threshold. Your savings or assets may also be taken into account when establishing your Medicaid eligibility.

Level of Care Eligibility

The level of care that is medically necessary and required determines whether a person is eligible for Medicaid, which varies from state to state. People must be able to demonstrate that they need a specific degree of care or a certain amount of personal care support to

be eligible for Medicaid.

The term “degree of care” has different meanings in different states, but generally speaking, it refers to support for people who have problems with their mental and behavioral health, lack cognitive function, and are unable to do activities of daily life. According to the American Council on Aging, these elements are only a few of the measures used to evaluate the quality of care provided at nursing facilities for senior citizens. Remember that the level of care varies by state, thus the requirements that could qualify one in one state might not apply in another.

Qualifying When You’re Over Medicaid Financial Limits

There are ways to still be eligible if you end up exceeding the Medicaid cap or losing your low-income status, such as through HCBS Medicaid waivers or initiatives like the Medically Needy Pathway. The latter, in particular, aids in extending Medicaid eligibility to people who earn more than the Medicaid income cap yet have rising medical costs for which they need financial assistance.

Do All Nursing Homes Accept Medicaid?

Medicaid is accepted by the majority of nursing facilities, however, your state of residence also has a significant impact on this. I’d advise asking your nursing home facility if they are a Medicaid-certified nursing facility to avoid issues with payment and coverage. If so, you ought to be qualified for Medicaid skilled care facility coverage.

You would have to move to a care facility that is covered by Medicaid if it turns out that the nursing home is not Medicaid-certified.

How to Apply for Medicaid Nursing Home Care

I would advise filling out a Medicaid application if you require assistance with nursing home care. Check first to discover if you qualify for Medicaid. Medicaid generally accepts applicants of any age and bases eligibility on family size and income. You might also need to provide citizenship documentation.

Then, I’d advise going to the official website of your state and submitting an application via the Health Insurance Marketplace or your state Medicaid office. It’s crucial to check that coverage is available for nursing facilities that have received Medicaid certification when applying for a specific Medicaid policy. Although completing a Medicaid application can occasionally be time-consuming or difficult, there are many tools available to assist you.

I advise going to Medicaid.gov for information on how to apply for Medicaid or get coverage for services linked to nursing homes. Read the following articles for more information about Medicaid and Medicare:

• What distinguishes Medicare and Medicaid from one another?
• Top Medicare Dental Supplement Plans
• Are Medical Alert Systems Covered by Medicare?
• Colonoscopies are covered by Medicare?
• Are Medicare premiums deductible from taxes?

FAQs

Nursing Home Costs in 2023

A private room in a nursing facility costs $297 per day, or $9,034, according to a 2021 Cost of Care Survey by Genworth.

What is considered Medicare coverage?

What components make up Medicare? Part A includes coverage for some home health care as well as inpatient hospital stays, care in skilled nursing facilities, and hospice care. Outpatient care, medical supplies, and preventative services are all covered by Part B.

When does Medicare cover nursing home care?

Services that assist with daily activities like dressing, eating, or using the restroom are typically not co