Nursing Home Care: What to Do When Medicare Wont Pay

Here's what to do when Medicare won't pay for a nursing home facility.

Senior woman with a crutch getting support from nurse at a nursing home.
(Image credit: Getty Images)

Many people will need to stay in a nursing home at some point in their lives. How much care they'll need and how long they need to stay, however, can be hard to predict. And unfortunately, Medicare won’t cover long-term care. For this reason, it’s important to plan ahead in case you (or a loved one) can no longer function on your own later in life and will have to pay for a nursing home.

In fact, the number of individuals needing long-term care is on the rise. According to a 2022 study from the Department of Human Health and Services, over half (56%) of Americans turning 65 today will develop a disability serious enough to require long-term care. The number of seniors needing long-term care is expected to rise from 6.3 million in 2015 to an estimated 15 million by 2050, reports the National Academy of Social Insurance. And the cost of nursing home care is also on the rise.

What is the cost of nursing home care?

According to estimates from Genworth’s Cost of Care Survey, the cost of a room in a nursing home facility is over $100,000 a year. And because Medicare won't pay for nursing home care, you’ll be responsible for the costs. Meanwhile, the estimated average monthly Social Security retirement benefit for January 2024 is $1,907, which adds up to just $22,884 a year. 

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Here are the estimated annual median costs in 2024 for various long-term care facilities.

 Nursing home facility

  • Private room: $120,304
  • Semi-private room: $107,146

Community and assisted living 

  • Adult day health care: $25,441
  • Assisted living facility: $66,126

 In-home care

  • Homemaker services: $70,699
  • Home health aide: $77,769

What to do when Medicare won’t pay

As mentioned above, Medicare will not cover a long-term stay in a nursing home, but it will cover limited stays in a skilled nursing facility. Following a qualifying hospital stay (admission for at least three consecutive days), Medicare Part A will cover the first 20 days in a skilled nursing facility if the patient begins receiving care within 30 days of their hospital discharge. According to the National Council on Aging, Medicare will only cover up to 100 days of care during each benefit period, but the patient will be responsible for $204 in coinsurance payments from day 21 to 100, after which they’ll pay 100% of costs.

Here’s what you can do to pay for long-term care. 

Medicaid coverage

If you meet the strict eligibility requirements, Medicaid will pay for 100% of nursing home costs. However, each state has its own eligibility requirements and coverage limitations. Generally though, Medicaid eligibility is dependent on income and personal resources. 

Under Medicaid, there are two sets of criteria you’ll need to meet in order to receive nursing home coverage — level-of-care criteria and financial criteria.

  • Level of care criteria: Nursing Home Level of Care (NHLOC) is a measure of care needs that must be met to qualify for nursing home coverage under Medicaid. Each state has its own criteria for NHLOC, which generally focus on an individuals cognitive function, physical functional ability and behavior problems.
  • Financial criteria: Each state has its own income and asset limits you'll need to meet to be eligible for Medicaid.

According to Medicare.gov, many states have higher Medicaid income limits for nursing home residents, and you can still be eligible for a nursing home under even if you haven’t qualified for other Medicaid services in the past. You may also opt to use a "Medicaid spend down," if your income exceeds the eligibility limit for Medicaid. This is where you spend the difference in your income and your state's Medicaid income limit on health care expenses, and once you reach the limit you qualify for Medicaid.

The National Council on Aging provides an example: "Imagine you’re on Medicare, a federal health insurance program for older adults, and your state’s Medicaid income limit is $2,000 a month. If your monthly income is $2,200, you must spend the $200 difference on health care costs, such as your Medicare premium. If you spent $250, Medicaid would pay the extra $50."

Long-term care insurance

One way to pay for a nursing home is by using long-term care insurance, which can cover both skilled and non-skilled care, depending on the policy. Since long-term care insurance can vary widely, make sure to do some research before you pick a policy to ensure the care you need is covered. A good place to start is by reading our advice on 10 things you should know about long-term care insurance.

A major factor to consider when shopping for long-term care insurance is cost. Unfortunately, this type of insurance can be expensive, and costs are usually dependent on age and gender. Because women live longer than men, they typically pay more. To keep costs down, it helps to purchase a policy when you're younger. Additionally, your coverage could be limited because of a pre-existing condition. 

The American Association for Long-Term Care Insurance found that for a policy offering $165,000 of total lifetime coverage, a 55-year old single male would pay an average annual premium of $900. At age 60, it would cost $1,200. A 55-year old single woman would pay $1500, while a 60-year old woman would pay $1,960. 

At-home care

Another option is to use at-home care, as both Medicare Part A and B cover eligible home health services for individuals who are homebound and need part-time skilled care. Here's what Medicare will cover at home:

  • Part-time skilled nursing care (examples: injections, tube feedings, changing dressing and administering IV drugs)
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology
  • Home health aide services (only if you are receiving skilled nursing care)
  • Medical social services (only if you are receiving skilled nursing care)
  • Medical supplies

However, there are several things that Medicare doesn't pay for that you or a loved one may need.

  • 24-hour care at home
  • Meals delivered to your home
  • Services, like shopping, cleaning and laundry
  • Custodial or personal care like bathing, dressing, and using the bathroom (when you do not require any skilled nursing care)

Nonprofit care

If available, it's possible to receive care from a nonprofit facility near you. Do some research and look for non-profit facilities that provide rehabilitation services or financial assistance.

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Erin Bendig
Personal Finance Writer

Erin pairs personal experience with research and is passionate about sharing personal finance advice with others. Previously, she was a freelancer focusing on the credit card side of finance, but has branched out since then to cover other aspects of personal finance. Erin is well-versed in traditional media with reporting, interviewing and research, as well as using graphic design and video and audio storytelling to share with her readers.