Medicaid and Medicare Skilled Nursing Coverage
Medicare and Medicaid can help seniors lower out-of-pocket skilled nursing costs.
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If you’re enrolled in Medicare or Medicaid and skilled nursing care is required as part of your road to recovery, you’ll need to know what to expect from these benefits. In this article, we’ll cover important details on Medicaid and Medicare skilled nursing coverage. Understanding skilled nursing eligibility, cost, and services provided is the first step in securing the best care (and avoiding an exorbitant bill at the end of your stay).
FYI: Medicare Annual Enrollment is here. Use our ZIP code Medicare search tool to compare plans in your area and get free quotes.
What Is Skilled Nursing?
Before we take a deep dive into Medicare and Medicaid skilled nursing coverage, it’s important to understand what skilled nursing is. Skilled nursing and skilled nursing facilities (SNFs) provide short-term care from skilled staff with specific expertise to treat patients. The goal of a skilled nursing facility is to help you recover to your best possible level of well-being.
Why would you need skilled nursing? If you have been hospitalized and are ready to be discharged, your doctor will assess whether you can return home or need additional care or therapy in an SNF. You will need to meet Medicare’s skilled nursing care eligibility requirements (we’ll cover this later in the article).
For example, the nursing care you receive in an SNF is supervised by doctors and is the same level of care you would receive at a hospital. You might need this if you need wound care treatment, IV medications, or rehabilitative care or therapies that will help you get ready to go home.
While skilled nursing sounds similar to nursing care, and the terms are sometimes used interchangeably, the two are quite different when it comes to Medicare coverage. This is essential to know, as Medicare coverage for skilled nursing facility services varies from coverage for a nursing home stay, even if the facility provides both.
Quick tip: Head over to our nursing home vs. skilled nursing guide for an in-depth look at the important differences in care.
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Does Medicare Cover Skilled Nursing?
Skilled nursing falls under Original Medicare Part A. Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility and ends when you haven’t received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row.
There are no limitations on the number of benefit periods. Before receiving Medicare-covered skilled nursing care, you must have a new three-day qualifying hospital stay each benefit period.
Medicare-covered skilled nursing services include the following:
- Semiprivate room
- Meals
- Skilled nursing care
- Ambulance transportation (when other transportation isn’t safe for your health)
- Physical therapy and occupational therapy
- Speech-language pathology services
- Medical social services
- Medications
- Medical supplies and equipment (also known as durable medical equipment) used in the facility
- Dietary counseling
From the experts: Whether you’re enrolling in Medicare for the first time or making changes during open enrollment, head to our guide on everything you need to know about Medicare enrollment.
Who Is Eligible for Skilled Nursing?
Medicare Part A (Hospital Insurance) may cover skilled nursing care on a short-term basis if all of these conditions are met:
- You are enrolled in Medicare Part A and have days remaining to use in your benefit period.
- You have a qualifying three-day inpatient hospital stay.
- Your doctor has determined you need daily skilled nursing care.
- Your skilled nursing care is administered in a Medicare-certified SNF.
Along with the above requirements, you may require skilled nursing coverage for a medical condition that’s either:1
- A hospital-related medical condition treated during your qualifying hospital stay, even if it wasn’t the reason you were admitted to the hospital.
- A condition that started while you received care in the SNF for a hospital-related medical condition.
Inside tip: Original Medicare is split up into hospital care and medical care. Learn the important details behind why we have Medicare Part A and Part B.
How Much Does Skilled Nursing Cost Through Medicare?
Your out-of-pocket costs will depend on the number of days skilled nursing care is required.2
- Days 1-20: $0 for each benefit period
- Days 21-100: Up to $200 coinsurance per day of each benefit period
- Days 101 and beyond: All costs
Keep in mind, though, that the average cost of a skilled nursing facility is around $324 per day, depending on where you live. So if your coinsurance covers up to $200 per day, you could still be responsible for a large bill.
Additional Cost Factors
Keep in close contact with your skilled nursing care team to confirm what is covered, what is not, and any coinsurance payments. It’s essential to follow through with the care your physician has established. If you refuse your daily skilled care or therapy, you could potentially lose your Medicare-eligible skilled nursing coverage.
Did You Know? Skilled nursing coverage falls under Medicare Part A. But what about Medicare Part B? Learn everything you need to know about Medicare Part B’s coverage and costs.
Another factor that may affect your out-of-pocket Medicare costs is additional services your health care provider orders. There may be instances when Medicare does not cover specific care, or the care may not be covered as often as your doctor wants. If this happens, you may have to pay for some or all of the recommended care or services.
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Does Medicaid Cover Skilled Nursing?
Medicaid provides health coverage to over 80 million Americans, including eligible low-income adults, seniors, and people with disabilities.3 Although Medicaid is a federal government program, individual states are responsible for decisions on coverage and benefits for Medicaid recipients.
If you have reached your limit of SNF care under Medicare or you don’t meet the requirements for Medicare to cover SNF, you may be able to have your stay covered by Medicaid.
Skilled nursing falls under Medicaid’s Nursing Facility Services. Eligible Medicaid recipients have to meet the criteria for SNF care in their own state, yet the individual states must also abide by federal law and regulations when setting their skilled nursing care requirements and guidelines.
According to federal requirements, Medicaid-covered skilled nursing services must provide the following:4
- Nursing and related services
- Specialized rehabilitative services
- Medically-related social services
- Pharmaceutical services
- Dietary services individualized to the needs of each resident
- Room and bed maintenance services
- Routine personal hygiene items and services
- Professionally directed program of activities to meet the interests and needs for the well-being of each resident
- Emergency dental services (and routine dental services to the extent covered under the state plan)
From the pros: Our Medicare and Medicaid health insurance guide shares all the essentials of Medicare and Medicaid, their differences, and how to know if you qualify for either (or both).
What if I Can’t Afford Skilled Nursing Coverage?
In addition to Medicaid, there may be other ways to get help paying for skilled nursing costs and other costs, including these programs:
Medicare Savings Programs
Program of All-Inclusive Care for the Elderly (PACE)
Supplemental Security Income (SSI)
Medicare Part D Extra Help
Pro Tip: Need clarification on coverage? Contact your State Health Insurance Assistance Program (SHIP) center. This state program provides free local health counseling to Medicare recipients.
Where Can I Find Medicare and Medicaid Skilled Nursing Care Near Me?
If you or your loved one are in the hospital and need the services of an SNF, the hospital care team is your first point of contact. They’ll discuss skilled nursing care options and verify the necessary treatment is administered in a nearby Medicare-certified or Medicaid-certified skilled nursing facility.
Quick tip: Medicare enrollees can easily search for Medicare-certified providers and facilities through Medicare’s Find & Compare search tool.
You can always speak directly to a Medicare or Medicaid representative by calling one of the following numbers.
- Medicaid recipients: Contact your State Medicaid Agency.
- Medicare recipients: Call 1-800-MEDICARE (800-633-4227). TTY users call 877-486-2048.
Centers for Medicare and Medicaid Services. (2019). Medicare Coverage of Skilled Nursing Facility Care.
Centers for Medicare and Medicaid Services. (2021). Skilled nursing facility (SNF) care.
Centers for Medicare and Medicaid Services. (2021). Medicaid.
Centers for Medicare and Medicaid Services. (2021). Nursing Facilities.
