Many families learn how Medicare covers nursing homes the hard way. A parent goes from the hospital to a skilled nursing facility for rehab, things go reasonably well, and then a staff member says Medicare is ending, often with a notice and a question about who will pay from here. At the same time, the family may be applying for Medicaid, dealing with a Medicaid health plan, or hearing about a screening that says nursing home care is no longer needed.
This guide covers the three situations that come up most: Medicare coverage ending, a Medicaid application still pending or a Medicaid plan stopping payment, and a PASRR resident review that finds nursing home care is not appropriate. For background, see Medicare vs. Medicaid for long-term care.
How Medicare covers nursing home care
Medicare Part A covers care in a skilled nursing facility on a short-term basis. Your parent must first have a medically necessary inpatient hospital stay of at least three days in a row, not counting the discharge day; time under observation or in the emergency room does not count. They must need daily skilled nursing or therapy that can only be provided safely by or under professionals1. Our guide to skilled nursing vs. nursing home care explains the difference, and our hospital discharge planning guide covers the hospital side. For more on why observation days don't count, see Medicare observation status.
| Days | What Medicare pays |
|---|---|
| Days 1 to 20 | All covered costs after the Part A deductible (unless already paid during the same benefit period) |
| Days 21 to 100 | Covered costs minus a daily coinsurance amount the patient pays |
| Day 101 and after | Nothing; the patient pays all costs |
Medicare Advantage plans may charge different copayments. Source: Medicare.gov.
The 100 days are a limit, not a promise. Coverage stops when daily skilled care is no longer needed, which often happens well before day 100. Skilled care to maintain your parent's condition or slow decline can also qualify; Medicare's own description includes care to improve, maintain or prevent worsening1. If the only reason given is that your parent has stopped improving, ask questions.
Medicare does not pay for long-term custodial care, the help with daily living that many nursing home residents need for months or years2. See how to pay for a nursing home for the other options.
The notice that Medicare is ending
Before Medicare-covered skilled nursing care ends, the facility must give your parent (or their representative) a Notice of Medicare Non-Coverage at least two days before covered services end. If you do not get one, ask for it3.
- Read the end date. It is the last day Medicare is expected to pay.
- Note the reviewer's contact. The notice names the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for your state, the independent reviewer for fast appeals.
- Ask for the detailed explanation. If you appeal, the facility must give a Detailed Explanation of Non-Coverage with the specific reasons and the Medicare rule it relies on3.
- Separate the two questions. Medicare ending is about payment. It does not by itself mean your parent must leave. Discharge has its own rules, covered below.
How to file a fast Medicare appeal
- Call the BFCC-QIO by the deadline. Follow the instructions on the notice no later than noon the day before the end date listed3.
- Tell the reviewer why care should continue. Describe what skilled services your parent still needs, such as wound care, therapy to keep walking, or monitoring of an unstable condition.
- Get support from the treating team. Ask the doctor or therapist whether they agree skilled care is still needed, and ask them to tell the reviewer.
- Request copies. You can ask for copies of the materials sent to the reviewer3.
- Watch for the decision. The reviewer generally decides by close of business the day after it gets the information it needs3.
If you miss the BFCC-QIO deadline and your parent has a Medicare Advantage plan, you can ask the plan for a fast reconsideration, but services are covered only if the decision is in your favor3. If the appeal fails, further appeal levels exist, and our upcoming guide to nursing home discharge rights will cover what the home can and cannot do next.
If Medicaid is pending
When Medicare ends and your parent still needs nursing home care, the next payer is usually private funds, long-term care insurance, or Medicaid. Many families apply for Medicaid at this point, and applications can take weeks or months.
Federal nursing home rules allow discharge for nonpayment only in specific circumstances. Nonpayment applies if the resident does not submit the paperwork needed for a third party such as Medicaid to pay, or if Medicaid or Medicare denies the claim and the resident refuses to pay. Once a resident becomes eligible for Medicaid after admission, the home may charge only what Medicaid allows5. In other words, a complete, timely Medicaid application that is still pending is generally not nonpayment.
- Apply promptly and completely. Missing documents are the most common cause of delays and denials. Keep copies of everything you submit and every notice you receive.
- Ask about retroactive coverage. Federal rules generally require states to make Medicaid effective up to three months before the month of application if the person was eligible and received covered services then6. Some states limit this, so confirm your state's rule with the Medicaid agency.
- Ask the business office about holds on billing. Many homes will wait on a pending application if they see it was filed and is moving. Get any arrangement in writing.
- Watch for denial notices. If Medicaid is denied, you have the right to a state fair hearing. Ask for one quickly and fix any missing information.
Our guide to Medicare vs. Medicaid for long-term care explains Medicaid's income and asset rules, spousal protections7 and estate recovery8.
If the nursing home says your parent must leave
A nursing home that participates in Medicare or Medicaid may transfer or discharge a resident only for limited reasons, such as the home can no longer meet the resident's needs, the resident's health has improved, safety or health of others is endangered, nonpayment as defined above, or the facility is closing5.
- Written notice, usually 30 days ahead. In most cases the home must give written notice at least 30 days before discharge. Shorter notice is allowed only in specific situations, such as urgent medical needs or a stay of less than 30 days5.
- What the notice must say. The reason, effective date and destination; appeal rights and how to file; and contact information for the State Long-Term Care Ombudsman5.
- Appeal to the state. States must provide a hearing system for residents to appeal discharge notices9.
- Staying during the appeal. When a resident appeals, the home generally may not discharge them while the appeal is pending, unless failing to do so would endanger the resident or others, and it must document that danger5.
If a Medicaid health plan stops paying
In many states, Medicaid nursing home care is managed by a health plan. If the plan decides to stop or reduce coverage for nursing home care, it must send a notice of adverse benefit determination. Federal managed care rules then give your parent appeal rights11.
- Appeal to the plan. Your parent has 60 calendar days from the date on the notice to ask the plan for an appeal11.
- Ask for continued benefits, fast. If the appeal is about ending or reducing services that were already authorized, the plan must continue them while the appeal is pending if you request continuation within 10 calendar days of the notice or by the date the change takes effect, whichever is later11.
- Go to a state fair hearing if needed. If the plan upholds its decision, your parent can request a state fair hearing, and can again ask to continue benefits if they act within 10 days11.
- Ask about repayment risk. If benefits continue and the final decision goes against your parent, the state may allow recovery of the cost of those continued services. Ask before you decide.
Keep the coverage appeal and any discharge notice separate. A plan's payment decision and the nursing home's discharge decision follow different rules, and you may need to appeal both.
If a PASRR review says nursing home care is not appropriate
Federal rules require states to screen nursing home applicants and residents who have a serious mental illness or an intellectual or developmental disability, through Preadmission Screening and Resident Review (PASRR). A resident review can be triggered by a significant change in condition, and the state decides whether the person needs nursing facility services and whether they need specialized services12.
- If nursing facility care and specialized services are not needed. The state must arrange a safe and orderly discharge and prepare and orient the resident for it12.
- If only specialized services are needed and the resident has lived there at least 30 months in a row. The state must offer the choice of staying in the nursing home or moving to an appropriate alternative setting, and explain the options12.
- If only specialized services are needed and the stay is shorter. The state must arrange a safe discharge and help the resident get specialized services elsewhere12.
- You can appeal. States must provide an appeal system for anyone adversely affected by a PASRR determination9.
A PASRR outcome is a state decision, not the nursing home's. Ask for the written determination and the appeal instructions, and contact the ombudsman or your state's protection and advocacy agency for help.
Veterans: other options to check
If your parent is a veteran, VA may provide or pay for nursing home care in some cases, including in VA community living centers, contracted community nursing homes and State Veterans Homes13. Wartime veterans and surviving spouses who need help with daily activities may qualify for VA Aid and Attendance, a higher pension rate that can help with care costs14.
Read moreVA Aid and Attendance: Who Qualifies and How to Apply
What to do this week
- Find every notice. Medicare non-coverage, Medicaid plan notices, discharge notices and PASRR letters. Note each deadline.
- File appeals on time. Medicare fast appeal by noon the day before the end date; plan appeal and continuation request within 10 days when you want services to continue.
- Start or finish Medicaid. Submit a complete application and keep proof of every submission.
- Ask for a care plan meeting. Discuss what your parent needs next and where those needs can be met safely.
- Line up help. SHIP for Medicare questions4, the ombudsman for residents' rights10, and your Area Agency on Aging for local services16.
- Plan the next setting. If your parent can leave safely, compare assisted living, care at home or another home with our nursing home guide.
If your parent's illness is terminal, compare hospice vs. palliative care, since hospice is a separate Medicare benefit. For a broader view of payment options, see paying for senior living, or take the care quiz.
