How Much Does Medicare and Medicaid Pay for Skilled Nursing Services?

Paying for long-term care isn’t cheap, and figuring out who pays what can be confusing. Many families find themselves stuck in a maze of rules when a loved one needs skilled nursing care. 

The good news? Both Medicaid and Medicare offer coverage, but they do so in very different ways. Knowing the difference can save time, stress, and money.

What Does “Skilled Nursing” Mean?

Skilled nursing services go beyond help with daily tasks. They involve medical care provided by licensed professionals, such as wound treatment, physical therapy, IV medications, or post-surgical recovery support. This kind of care usually happens in a skilled nursing facility (SNF), especially after a hospital stay or during serious health conditions that need medical attention.

Does Medicare Pay for Skilled Nursing?

Yes, under particular circumstances. Medicare covers skilled nursing services if:

1. You’ve had a qualifying three-day inpatient hospital stay.
2. Your doctor recommends daily skilled care.
3. You enter the SNF within 30 days of your hospital discharge.

Here’s how the payment breaks down:

• Days 1–20: Medicare covers 100% of approved costs.
• Days 21–100: You’ll pay a daily coinsurance (in 2024, that’s $204 per day).
• After Day 100: You’re responsible for the full cost unless you qualify for Medicaid.

So, Medicare is helpful, but temporary. It’s designed more for short-term recovery than for long-term residence care.

Medicaid Skilled Nursing Facility Coverage: What to Know

Medicaid steps in where Medicare leaves off. It’s the largest payer of long-term care services in the U.S., covering millions of seniors in skilled nursing facilities. But it comes with its own set of rules.

To qualify, you need to meet Medicaid requirements for skilled nursing facility care. These typically include:

• Financial eligibility: Income and asset limits vary by state, but many require you to spend down your assets before qualifying.
• Medical necessity: You must need a level of care that only a skilled nursing facility can provide.
• Residency and citizenship: You must be a U.S. citizen or qualified immigrant and reside in the state where you’re applying.

What Does Medicaid Pay for in a Nursing Home?

Once you qualify, Medicaid skilled nursing facility coverage includes:

• Room and board.
• Nursing care.
• Meals and dietary services.
• Rehabilitation (PT, OT, speech therapy).
• Prescription drugs.
• Basic personal needs (toiletries, hygiene items).

It’s worth noting that while Medicaid covers most essentials, there may still be minor costs for extras like private rooms, non-covered medications, or specialized therapies.

How Medicaid and Medicare Work Together

Many people are “dual eligible,” meaning they qualify for both programs. In that case, Medicare pays first, covering up to 100 days of skilled care if all requirements are met. After that, Medicaid kicks in to cover ongoing care.

This handoff is crucial because once Medicare stops paying, the out-of-pocket costs can soar. Medicaid acts as a financial safety net, stepping in to cover the gaps, including daily charges that Medicare no longer pays after the 100-day mark.

Planning Ahead: Avoid Financial Surprises

Don’t wait until a crisis hits to figure out how to pay for nursing home care. Taking steps early on can protect your loved one’s savings and make qualifying for Medicaid much smoother when the time comes. Here are some important actions to consider:

• Speak with an elder law attorney to plan Medicaid eligibility

An experienced elder law attorney can help you understand the complex Medicaid rules in your state. They can guide you through legal strategies to protect assets, such as setting up trusts or making allowable transfers, so you don’t unintentionally disqualify yourself from benefits. Early legal advice is invaluable in avoiding costly mistakes.

• Keep thorough medical records to prove the need for skilled care.

Medicaid approval depends heavily on medical necessity. Having detailed documentation from doctors, therapists, and hospitals that clearly shows the level of care required will strengthen your application. This can include hospital discharge notes, physician assessments, and therapy records to show why skilled nursing care is essential.

• Understand state-specific Medicaid income and asset limits.

Medicaid rules vary widely from state to state. Knowing your state’s income thresholds and asset limits ahead of time will help you plan your finances accordingly. Some states have programs or “spend down” options that allow you to reduce countable assets legally to meet eligibility, so being informed is key.

• Explore Medicaid waiver programs for home-based care if facility care isn’t needed yet

Not everyone who needs skilled nursing must move into a facility right away. Many states offer Medicaid waiver programs that provide funding for home health care or community-based services. These options can help your loved one stay comfortable and independent at home while still receiving necessary medical support.

By preparing early and understanding your options, you’ll avoid unexpected costs and stress during what can already be a challenging time. Taking these proactive steps ensures a smoother path to securing the care your loved one deserves.

FAQ

How long will Medicare cover skilled nursing care?

Medicare covers up to 100 days per benefit period, as long as eligibility requirements are met.

What happens when Medicare stops paying?

You’ll be responsible for the full cost unless you qualify for Medicaid or have private long-term care insurance.

Can I apply for Medicaid while in a nursing home?

Yes. Many people start the application process once they realize Medicare coverage is ending.

Does Medicaid cover a private room in a nursing home?

Typically, no. Medicaid usually pays for a shared room unless a private room is medically necessary.

What’s the difference between custodial care and skilled nursing care?

Custodial care helps with daily activities like bathing and dressing. Skilled care includes medical treatment provided by licensed professionals.

The costs of long-term skilled nursing care can be daunting, but you’re not without options. While Medicare offers short-term help, Medicaid skilled nursing coverage is the long-haul solution for those who qualify. 

Understanding Medicaid requirements for skilled nursing facility care, knowing what Medicaid pays for in a nursing home, and planning ahead can make all the difference when navigating this complex but critical part of senior healthcare.

Contact BrightStar Care of Arlington/Alexandria Today! 

BrightStar Care of Arlington/Alexandria is here to provide you with the resources and support you need to take care of your loved one. We understand the challenges faced by caregivers and are committed to providing compassionate care that meets the needs of those we serve. 

If you would like more information about our services, please visit our website or call us today at (703) 267-2380. It will be a pleasure to meet you and your family, and we look forward to providing you with the care and support you need. Come visit us at 1727 King St, Suite 2, Alexandria, VA 22314. 

Hopefully, we’ll hear from you soon!