Does Medicare Pay for Nursing Homes?

Q. I read that Medicare doesn’t pay for staying in a nursing home. But my friend is in a nursing home, and she says Medicare’s picking up the tab. Who’s right?

A. Both are right. Medicare doesn’t normally cover “custodial” care for people who live in nursing homes or other long-term care facilities. Custodial care means help with daily living activities, such as eating, getting in and out of bed, washing and bathing, going to the toilet and moving around. Paying for this type of care is your own responsibility, unless you have long-term care insurance that covers it or you qualify for Medicaid benefits from your state.

But there’s one exception. Medicare’s skilled nursing facility (SNF) benefit covers a temporary stay in a nursing home in certain circumstances.

How to qualify for the SNF benefit:

* You must have Medicare Part A hospital insurance.

* You must have spent at least three days as an admitted patient in the hospital. Days spent "under observation" in the hospital do not usually count toward the three days.

* Your doctor must order that you need skilled nursing services as a result of the same illness or injury that put you in the hospital, or because of a new one that developed while you were there. For example, you may need continuing intravenous injections or physical therapy.

* The services your doctor ordered can be provided only on an inpatient basis at a Medicare-certified SNF (either a nursing home or hospital).

What you get:

Medicare covers up to 100 days in a skilled nursing facility. This includes medical and nursing services, custodial care, semiprivate room, meals and prescription drugs. (Any drugs you need while receiving the SNF benefit are paid for under Medicare Part A hospital insurance, not under Medicare Part D drug coverage.)

What you pay:

* Days 1 to 20: You pay nothing. Medicare pays 100 percent of the cost.

* Days 21 to 100: You pay a daily copayment—$137.50 in 2010—and Medicare pays the rest. (If you have medigap supplementary insurance, long-term care insurance or are in a Medicare Advantage health plan, some or all of this cost may be covered, depending on your policy or plan.)

* Beyond 100 days: You pay the full costs and Medicare pays nothing. (Long-term care insurance may cover part of the costs.)

For more information (including how to find SNFs in your area and assess their quality), see Medicare’s publication “Medicare Coverage of Skilled Nursing Facility Care,” available in English or Spanish.

Patricia Barry is a senior editor at the AARP Bulletin.