Medicare Nursing Home Coverage

The U.S. Department of Health and Human Services says that the average cost for a semi-private room in a nursing care facility is roughly $225 a day, $6,844 per month, and $82,128 per year.

And if you want a private room, you can expect to pay more. The costs are somewhere around $253 per day, $7,698 for an entire month, and a total of $92,376 annually.

The question is, how much of these costs will Medicare cover?

Original Medicare and Nursing Home Benefits

In Your Guide to Choosing a Nursing Home or Other Long-Term Services & Supports, the Centers for Medicare & Medicaid Services (CMS) says that if you have Original Medicare, a majority of your nursing home care expenses will not be covered.

While there are some benefits under Part A (hospital insurance), they are extremely limited and typically only apply to “medically necessary” skilled nursing care due to an illness or injury that meet specific conditions. Even then, they’re generally only covered for a limited time.

Medicare does offer at least partial benefits toward the following, among others, according to Medicare.gov:

• Skilled nursing care
• Physical or occupational therapy
• Medications
• Medical supplies used while in the facility
• Ambulance transportation (under certain circumstances)
• A semi-private room
• Meals and dietary counseling

To be eligible for coverage related to these skilled nursing care expenses, participants must have a qualifying hospital stay (usually three days), have days left in their benefit period, and choose a facility that works with the Medicare program.

The skilled nursing facility must also be doctor-recommended, and will generally only be covered for patients with a hospital-related medical condition or a condition that started while already in a skilled nursing facility.

Nursing Home Costs with Medicare

With Original Medicare, your expected costs related to skilled nursing home care depend largely upon how long you need the care.

Here is a breakdown of these costs as provided by Medicare.gov:

Medicare Advantage Nursing Home Benefits

If you have Medicare Advantage—also known as Medicare Part C—or any other type of Medicare-approved health insurance plan, the CMS says that the individual plan dictates whether any nursing home care coverage is provided and, if so, to what extent.

However, the CMS also says that most plans will not contribute to this type of extended care unless a nursing home has a contract with a particular plan.

Medicare Prescription Drug Coverage and Nursing Home Care

When in a skilled nursing facility that is Medicare approved, prescription drug coverage is typically provided via Medicare Part A, according to the CMS.

Yet, prescription drug costs incurred while living in a nursing home or similar institution are also sometimes covered via Medicare Part D or a Medicare Advantage plan, if you have either of these.

Other Nursing Home Coverage Options

There are a few additional ways to get help with growing nursing home costs beyond the limited expenses Medicare agrees to pay.

The first is Medicaid. The CMS explains that Medicaid eligibility is determined based on both income and resources. Additionally, this eligibility amount is generally higher for participants living in a nursing home than for the general Medicaid recipient.

A second option is long-term care insurance. Depending on the individual policy, this type of insurance may cover nursing home care, assisted living, adult day care, or even informal care at home.

Nursing home expenses can also be paid using money you’ve saved or invested over the years, with some life insurance policies having provisions for paying these costs as well.

Finding the Right Nursing Home for You

To find and compare Medicare-certified nursing homes in your area, Medicare.gov offers an online search based on where you live.

The site also offers a Nursing Home Checklist to take with you when visiting potential homes in person. This document provides a number of factors to consider before deciding on one, such as:

• Staff actions and appearance
• The state of the living spaces
• Resident room space and rules
• Menu and dietary options
• Available activities
• Safety procedures

Nursing home care can be costly, but some options exist that can help pay for some or all of it. And while it is limited, Medicare is one of these options. Medicaid, long-term care insurance, and even personal financial resources can be considered as well.

Either way, it’s important to choose the right nursing home for you or your loved one.