Nursing Facilities
Check Medicare Eligibility
For many nursing home residents, Medicare fully covers care only during the first 20 days following a hospital stay — and provides only partial payment after 20 days, up to a maximum of 100 days. Coverage is restricted to skilled nursing or rehabilitation services only. Also, the facility must be certified by Medicare and agency officials must approve the need for the care before it will pay anything.
Medicare does not pay for the cost of care in a Congregate Living Health Facility, with the exception of limited therapy or nursing visits that qualify as home health care or hospice care at the end of life.
Who Is Eligible
Medicare is a federal health insurance program for people age 65 and older, some disabled people under 65, adults who receive Social Security payments, and those with end-stage renal disease.
To find out more about eligibility, use the Medicare Eligibility and Enrollment Date Calculator.
What Is Covered
Medicare coverage has two parts:
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Part A pays for most inpatient hospital care, some inpatient skilled nursing home care, some home health care, and hospice care.
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Part B pays for doctors’ services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies. Those who don’t automatically qualify for Medicare because they receive Social Security payments may get coverage by paying a premium.
Medicare covers care received in a Medicare-certified nursing home for only a short time — up to 100 days. While this is not a long term solution, it gives patients and families a little breathing room to find and finance a facility if extended care is needed.
Coverage includes daily skilled nursing or rehabilitation services following a hospital stay provided by a registered nurse, or physical, speech or occupational therapist.
Coverage is allotted as 100 days per illness. The first 20 days are covered in full; the additional 80 days require a copayment. The 100 days are not automatically guaranteed — and Medicare must approve the length of stay in the facility. If Medicare decides that daily skilled nursing or rehabilitation is no longer needed, payments stop. Residents must then pay out-of-pocket, use private insurance, or seek Medi-Cal coverage. If the facility does not accept the new type of payment, then the resident will have to be moved.
Medicare will not pay to hold a bed if a resident needs to leave temporarily to receive care in a hospital.
How to Apply
Those who already receive Social Security benefits are automatically enrolled in Medicare Part A and Part B the month they turn 65.
Those who wish to apply for both Social Security benefits and Medicare can apply online — as long as they are at least 61 years and 8 months old, and want to start benefits within the next four months.
Those who wish to apply for Medicare alone must call the Social Security Administration at 800-772-1213 or 800-325-0778 (TTY) or contact the local Social Security office.
Other Medicare-approved Plans
A number of plans that are approved by Medicare but run by private companies offer health and prescription drug coverage. For example, Medicare Advantage plans provide Part A and B benefits, but charge different amounts for certain services — and may offer more coverage for an extra cost. Medicare Advantage Plans are HMOs, PPOs, or private fee-for-service plans. If you are enrolled in a Medicare Advantage plan, Medicare services are covered through the plans and are not paid for under Original Medicare.
Other plans, including Medicare Cost Plans and Demonstration or Pilot Programs, provide coverage for Parts A and B, with some also covering prescription drugs. While these plans are offered to increase the number of coverage options available to consumers, there are still confusing kinks in timing, coverage, and cost. For specific questions, contact the main Medicare office at 800-633-4227 or 877-486-2048 (TTY).
For more information on Medicare coverage of nursing home care, visit the Medicare Web site.
For more information on Medicare coverage and its costs, including free individual counseling, contact the local office of the Health Insurance Counseling & Advocacy Program (HICAP).
For advocacy and education about Medicare, contact California Health Advocates.
Medigap Coverage
Medigap insurance, or Medicare supplemental insurance, is designed to cover the “gaps” between what Medicare does and does not pay. While the policies do not specifically cover nursing home care, they are often an important part of an insured’s complete plan.
In California, 12 standard Medigap plans are sold by private insurance companies, regulated by state and federal law, and must be clearly labeled as Medicare supplements and identified by the letters A through J.
Plan A, the basic benefit package, covers:
- Medicare Part A co-insurance, plus coverage for 365 additional days of hospitalization after Medicare benefits end;
- Medicare Part B co-insurance (the 20% of medical services that Medicare does not pay);
- The first three pints of blood each year, which Medicare does not pay; and
- Medicare Preventive Care Part B co-insurance.
The other packages contain various combinations of additional benefits, which may include:
- Hospice care co-insurance or copayment;
- Skilled nursing facility care co-insurance;
- Medicare Part A deductible;
- Medicare Part B deductible;
- Medicare Part B excess charges;
- Foreign travel emergency coverage;
- At-home recovery coverage; and
- A limited amount of preventive care not covered by Medicare.
For more information and guidance on buying Medigap policies and an explanation of rights under them, see "Choosing a Medigap Policy — A Guide to Health Insurance for People with Medicare."
Dual Coverage with Medi-Cal
Some people who qualify for Medicare benefits and have low income and assets levels may also qualify for full Medi-Cal coverage (California’s Medicaid program). For such people, known as “dual eligibles” or “Medi-Medis,” Medicare will first pay for the benefits it covers and Medi-Cal will provide secondary coverage. Also for those with such dual eligibility, Medi-Cal may cover deductibles and copayments for Medicare Part A and pay for Part B premiums.
