Navigating Medicare Nursing Homes - What Seniors in the USA Need to Know

When considering nursing home care in the United States, seniors and their families often look to Medicare for support. However, the precise extent of Medicare's coverage for these services can be complex and confusing.

Navigating Medicare Nursing Homes - What Seniors in the USA Need to Know

This comprehensive guide is designed to demystify Medicare's role in nursing home care, explaining what benefits are available, how to locate facilities certified by Medicare, and important factors seniors should weigh when planning for their long-term care needs.

Understanding Medicare's Role in Nursing Home Care

It's vital to distinguish between a "nursing home" and a "skilled nursing facility" (SNF) when it comes to Medicare. While the terms are sometimes used interchangeably in everyday conversation, Medicare makes a clear distinction that directly impacts coverage.

  • Skilled Nursing Facility (SNF): Medicare does cover short-term stays in a skilled nursing facility. An SNF provides a higher level of medical care and rehabilitation services, such as physical therapy, occupational therapy, speech-language pathology, wound care, or intravenous (IV) therapy. The primary goal of an SNF stay is typically to help a patient recover from an illness, injury, or surgery and return home or to a lower level of care.
  • Nursing Home (Long-Term Care/Custodial Care): Medicare does not generally cover long-term "custodial care" in a nursing home. Custodial care refers to non-medical assistance with daily activities like bathing, dressing, eating, and using the bathroom. This type of care is often needed for chronic conditions or disabilities that require ongoing support, rather than a short-term recovery.

Key Medicare Coverage for Skilled Nursing Facilities (SNFs):

If you meet specific criteria, Medicare Part A (Hospital Insurance) can cover a portion of your skilled nursing facility stay. Here's what you need to know:

  1. Qualifying Hospital Stay: You must have had a qualifying inpatient hospital stay of at least three consecutive days (not including the day of discharge) before entering the SNF.
  2. Medical Necessity: A doctor must certify that you need daily skilled nursing care or skilled therapy services for a condition that was treated during your hospital stay, or for a new condition that developed while you were in the hospital or SNF.
  3. Medicare-Certified Facility: The SNF must be Medicare-certified.
  4. Timely Admission: You generally must enter the SNF within 30 days of leaving the hospital.

What Medicare Part A Covers in an SNF (2025 figures):

  • Days 1-20: Medicare covers 100% of the eligible costs. You pay nothing.
  • Days 21-100: You pay a daily coinsurance of $209.50. Medicare covers the rest.
  • Days 101 and beyond: You are responsible for all costs.

Important Note: These benefits are per "benefit period." A new benefit period begins after you've been out of a hospital or SNF for 60 consecutive days. There's no limit to the number of benefit periods you can have.

Other Medicare Parts and Nursing Home Care:

  • Medicare Part B (Medical Insurance): While Part B doesn't cover SNF stays, it can cover certain medically necessary services you receive while in a nursing home, such as doctor's visits or some rehabilitation therapies after your Part A SNF benefits run out.
  • Medicare Part C (Medicare Advantage Plans): These private plans, approved by Medicare, must cover at least the same benefits as Original Medicare (Parts A and B). Some Medicare Advantage plans may offer additional benefits related to SNF care, and some Special Needs Plans (SNPs) are specifically designed for individuals who need a high level of skilled nursing care or reside in an SNF for an extended period. Always check with your specific plan for details.
  • Medicare Part D (Prescription Drug Coverage): Part D plans cover prescription drugs, which are usually dispensed by a long-term care pharmacy that contracts with the nursing home.
  • Medigap (Medicare Supplement Insurance): These plans can help cover some of the out-of-pocket costs of Original Medicare, including the daily coinsurance for SNF stays (Days 21-100). However, Medigap plans do not cover long-term custodial care.

How to Find Medicare-Certified Nursing Homes

Finding a Medicare-certified nursing home is crucial for potential coverage. The official government resource for this is the Medicare.gov Care Compare tool.

Using the Care Compare Tool:

  1. Visit Medicare.gov/care-compare: This is the official website managed by the U.S. Centers for Medicare & Medicaid Services (CMS).
  2. Select "Nursing Homes": The tool allows you to search for various healthcare providers.
  3. Enter Location: You can search by ZIP code, city, or state.
  4. Refine Your Search (Optional): You can also search by facility name.
  5. View Results: The results will show Medicare-certified nursing homes in your area, along with their overall star ratings.

The Care Compare tool provides valuable information for each facility, including:

  • Overall Star Rating: A rating from 1 to 5 stars, with 5 being "much above average." These ratings are based on health inspections, staffing, and quality measures.
  • Detailed Star Ratings: Separate ratings for health inspections, staffing, and quality measures.
  • Health Inspection Reports: Information on deficiencies found during state inspections.
  • Staffing Information: Details on the hours worked by different types of staff per resident per day, and staff turnover rates.
  • Quality Measures: Data on various aspects of resident care, such as residents with pressure ulcers or those who experienced a fall.

Sources for Finding Medicare-Certified Nursing Homes and Their Ratings:

Important Considerations for Seniors

  • Long-Term Care Costs: Be aware that Medicare generally does not cover long-term custodial nursing home care. The vast majority of long-term nursing home costs are paid out-of-pocket, through long-term care insurance, or through Medicaid for those who qualify.
  • Medicaid: Medicaid is a joint federal and state program that can help with nursing home costs for individuals with limited income and resources. Eligibility rules vary by state, and not all nursing homes accept Medicaid.
  • Veterans Benefits: Veterans may be eligible for long-term care services through the VA Health System.
  • Pre-Planning: It's highly recommended to plan for potential long-term care needs well in advance, as Medicare's coverage for nursing homes is limited to skilled, short-term stays.
  • Visiting Facilities: Always visit potential nursing homes in person. Use resources like the Medicare Nursing Home Checklist (available on Medicare.gov) to guide your questions and observations.
  • Ask About Services: Understand what services are included in the daily rate and what might be extra. Inquire about the types of activities offered, dietary options, and how medical appointments are handled.

Nursing Homes in the USA

Here's a non-exhaustive list of nursing homes that can be found on the Care Compare tool, providing a glimpse of the types of facilities available across the U.S. Please remember that facility information and ratings can change frequently. For the most current and comprehensive details, the Medicare.gov Care Compare tool remains the official and most reliable source for finding Medicare-certified nursing homes in any U.S. location and viewing their current star ratings and detailed inspection reports.

  • The Cedars Nursing Care Center (Portland, ME)
  • Mainegeneral Rehab & Long Term Care - Glenridge (Augusta, ME)
  • Norway Center for Health & Rehabilitation, LLC (Norway, ME)
  • Gorham House (Gorham, ME)

These are examples of real facilities that appear in searches on Medicare.gov, and their specific ratings can be accessed by using the search tool and entering the relevant location. The ratings are dynamic and reflect ongoing assessments by government agencies.

To find specific facilities and their ratings in your area, please use the official Medicare.gov Care Compare tool. This ensures you have access to the most current and verifiable information directly from the Centers for Medicare & Medicaid Services.

Conclusion

Understanding Medicare's role in nursing home care is crucial for seniors and their families. While Medicare provides excellent coverage for short-term, medically necessary skilled nursing facility stays, it is not designed to cover long-term custodial care. By utilizing official resources like the Medicare.gov Care Compare tool and planning ahead, seniors can make informed decisions about their healthcare and long-term care needs in the United States.

Sources

Derek Harnett