Medicare vs. Medicaid Nursing Home Coverage
Medicare and Medicaid are complex and can be confusing when it comes to understanding what each program covers when it comes to nursing home stays and senior rehabilitative services. We’ve compiled some of the most common questions we hear – and answers. Regulations and coverage change and may vary from state to state, so be sure to check with your provider.
- What is the difference between Medicare and Medicaid?
Medicare primarily provides health benefits for those over age 65 or people with disabilities. Medicaid primarily provides health benefits for low-income people. In some cases, people may be eligible for dual Medicare and Medicaid benefits. Medicare does not cover long-term nursing care.
- When will Medicare cover my stay at a skilled nursing center?
Typically, Medicare covers short-term care at a nursing home or rehabilitative center if:
- You were formally admitted to the hospital and spent at least three consecutive midnights as an inpatient. People admitted to the hospital under observation status do not qualify. Observation status means that you are receiving services as an outpatient even though you are staying in the hospital. This typically results in higher out-of-pocket expenses and less Medicare benefits. If admitted to a hospital, we recommend inquiring about your status.
- You are transferred to a nursing home or rehabilitation center for ongoing care of a condition that required a hospital admission or skilled nursing services
- Your physician certified that you require skilled nursing or rehabilitative care after your hospital stay
- A condition for which you were admitted to a hospital or skilled nursing center worsens within 30 days after returning home
- What parts of my skilled nursing stay are covered by Medicare?
If you meet the criteria for a covered short-term nursing care stay, Medicare will cover a semi-private room, meals, your nursing care, social services, and medical supplies. If the following items are needed to meet your health goal, Medicare also covers physical, occupational, and speech therapy, medications, ambulance services to ancillary services, and dietary counseling. Other benefits may apply as necessary.
- How much will Medicare reimburse of my short-term care expenses?
Typically, Medicare Part A will cover 100 percent of your short-term stay expenses for up to 20 days. For days 21 through 100, the patient is responsible for a daily coinsurance charge. If you have a Medicare Advantage Plan, called Part C, this may be covered by the plan. After 100 days, Medicare does not cover any part of your expenses unless you meet limited qualifying circumstances.
- Does Medicaid cover my stay at a skilled nursing center?
Medicaid will reimburse long-term skilled nursing care if you meet the need for such services and if you have exhausted your financial assets to the state-mandated level and meet medical criteria as determined by the state.