The short answer
Medicare Part A covers up to 100 days of skilled nursing facility care in each benefit period, not each year. It starts only after a qualifying inpatient hospital stay of at least three days in a row. Medicare does not cover custodial care when that is the only care you need.
You type the words nursing home into a search box, and Medicare has two pages waiting for you. One of them says the care is covered. The other says it is not. Which one is true for you depends on the kind of care you need, and on something that happened in the hospital before you ever got there.
How many days does Medicare cover in a nursing home?
Medicare Part A limits skilled nursing facility coverage to 100 days in each benefit period. The clock is the benefit period rather than the calendar year, so the same 100 days can come round again. Care that is only help with daily living falls outside it.
Call the shape of this Two Doors, One Building. Medicare.gov publishes two coverage pages about the same kind of place and gives them opposite headline verdicts. Its nursing home page leads with the words "Not Covered". Its skilled nursing facility page leads with "Covered by Part A".
Both pages are the government's, and both are correct. The split, and the fact that the word a reader types decides which of the two they land on, is ours.
The building is not what settles it. Medicare's own nursing home page says these facilities can provide two different things: short-term care for someone recovering after surgery or an illness, and long-term help with bathing, dressing or eating. The first can be covered. The second is the one the headline is about.
Medicare labels the covered version plainly on its skilled nursing page. Covered by Part A, for a limited time, on a short-term basis. Every rule further down this page is an answer to what limited and short-term actually mean.
What is the 3-day hospital stay rule?
Medicare covers skilled nursing facility care only after a qualifying inpatient hospital stay. That means a medically necessary inpatient stay of at least 3 days in a row, counted from the day you were admitted as an inpatient and not counting the day you leave.
That arithmetic is the whole rule, and it is why three nights in a building is not the same thing as a three day stay. Medicare publishes two worked situations to show the difference, and they are worth reading in its own terms.
In the first, you come to the emergency department and are formally admitted with a doctor's order as an inpatient for 3 days, then discharged on the fourth. Medicare's answer is yes, the requirement is met.
In the second, you come to the emergency department, spend one day getting observation services, and are then admitted as an inpatient for two more days. Three days pass. Medicare's answer is no.
The reason the second one fails is stated on the same page. Time you spend under observation or in the emergency room before you are admitted does not count toward the 3-day qualifying inpatient hospital stay, even if you are there overnight.
There is a second 3 day rule in Medicare and it is not this one. The other one reaches backwards over the three days before an admission for billing purposes, once an admission has already happened. This one is an entry condition that has to be met before skilled nursing coverage can begin at all. Same number, opposite directions.
Two escape hatches exist and Medicare names both. You may not need the 3 day minimum if your doctor takes part in an Accountable Care Organization approved for a Skilled Nursing Facility 3-Day Rule Waiver, and Medicare Advantage Plans may also waive it. Medicare's instruction in both cases is to ask your doctor or hospital staff whether your stay will be covered.
One more clock runs beside these. You have to enter the facility within a short time of leaving the hospital, which Medicare puts at generally 30 days.
What do I pay per day in a skilled nursing facility?
What you owe runs in three bands measured by benefit period. Days 1 through 20 carry nothing per day once the Part A deductible is settled. Days 21 through 100 carry a fixed daily amount. From day 101 you pay all costs.
Two mechanics sit inside those bands and neither is obvious from the ladder itself.
The first works in your favor. You do not have to pay the Part A deductible for skilled nursing facility care if you already paid it for care you got in a hospital during the same benefit period. One benefit period, one deductible, even though the care happened in two buildings.
The second cuts the other way. If you are in a Medicare Advantage Plan, you may be charged copayments during the first 20 days, which is the band that costs nothing per day under Original Medicare. Medicare's instruction is to check with your plan.
The doctors are billed separately from the room. Medicare states that Part B covers doctor visits and physical, speech or occupational therapy even when you get those services while you are in a nursing home.
The actual amounts for each band are plan year figures, and on this publication they belong to the Part A cost page rather than to this one. What belongs here is the shape: three bands, counted by benefit period, with everything falling on you from day 101.
What does skilled nursing include?
A covered stay brings a shared room, meals, skilled nursing care, and the therapies your health goal needs. It also brings medical social services, medications, supplies and equipment used in the facility, dietary counseling, and ambulance transport when other travel would endanger your health.
Medicare's own list carries a hedge worth keeping. It says these services are included, but are not limited to, the items it names. The list describes the shape of the benefit rather than closing it.
The word skilled is the one doing the work. Medicare defines skilled care as nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel.
It adds what that care is for: treating, managing and observing your condition, and evaluating your care. Each of the three therapies on the list carries its own condition, that it is needed to meet your health goal.
The ambulance line carries two conditions rather than one. It covers transport to the nearest supplier of needed services that are not available at the facility, and only when other transportation would endanger your health.
When does coverage end?
Coverage ends at 100 days in a benefit period, and it can end sooner. Refusing your daily skilled care or therapy can end it. So can leaving, because what happens next depends entirely on how long the break in skilled care lasts.
Medicare states the refusal rule plainly and then softens one edge of it. If you refuse your daily skilled care or therapy, you may lose your skilled nursing facility coverage. If a condition keeps you from getting skilled care, such as catching the flu, you may be able to keep coverage temporarily.
What happens after a break in skilled care runs on two different thresholds, and they answer two different questions.
| The break in skilled care | What it takes to get more days | The trap |
|---|---|---|
| Under 30 days | No new hospital stay is needed | Assuming any gap ends your coverage |
| More than 30 days | A new 3 day hospital stay | The new stay can be another condition |
| At least 60 days in a row | The benefit period ends and days renew | This break is also over 30 days |
The two thresholds answer two different questions. The 30 day one decides whether you need another hospital stay. The 60 day one decides whether the meter goes back to the top.
Medicare's own wording on the longer break is worth having exactly: a break of at least 60 days in a row ends your current benefit period and renews your benefits, so the maximum available would be up to 100 days again.
Going back to hospital raises a separate question about the bed. Medicare says there is no guarantee a bed will be available at the same facility afterwards, and its instruction is to ask whether the facility will hold one for you and whether holding it costs anything.
Medicare adds one line about disagreeing with the ending. If you disagree with your discharge for any reason, you can appeal.
What if I need long-term care?
Long-term care is help with the basic tasks of everyday life, like bathing, dressing or eating. Medicare does not cover custodial care when that is the only care you need, and it generally does not cover a long-term nursing home stay.
The exception is inside that sentence. Medicare's wording is that it generally does not cover long-term nursing home stays unless you are receiving skilled nursing care, which points straight back at everything above.
So the same person, in the same bed, can be inside the benefit one month and outside it the next, without moving. What changed is whether the care being given still counts as skilled.
Medicare names one route when the qualifying stay never happened. Its instruction, for someone who has no 3 day qualifying inpatient hospital stay and needs care after leaving hospital, is to ask whether care is available in other settings, such as home health care. It adds a second question: whether any other program, such as Medicaid or Veterans' benefits, can cover the facility care.
That is a list of doors to knock on rather than an answer, and Medicare states it as one. What long-term care costs, who pays for it, and what part Medicaid plays are separate questions with separate answers.
What this means for you
The 100 days are real, and they are counted by benefit period rather than by year. Getting to them takes a qualifying inpatient hospital stay of at least 3 days in a row, and the hours before an admission order do not count toward it.
Coverage can also end before the 100 days run out. Refusing daily skilled care can end it, and a break of more than 30 days means a new hospital stay before any more days are available.
If the care you need is help with everyday living rather than skilled nursing, the answer is on Medicare's other page, and the Coverage section carries home health care and hospice for the two routes that sit beside this one.
FAQ
Do hours in the emergency room count toward the 3-day stay?
No, and Medicare states it twice. Time you spend at the hospital under observation or in the emergency room before you are admitted does not count toward the 3-day qualifying inpatient hospital stay, even if you are there overnight.
Its own worked example shows what that costs. A person who spends one day getting observation services and is then admitted as an inpatient for two more days has been in the hospital for three days, and Medicare's answer on whether the facility stay is covered is no, because the observation days were outpatient days.
The count starts at the admission order, runs for at least 3 days in a row, and does not include the day you leave the hospital. Asking about your status each day is the only way to know which kind of day you are having.
What happens if I have to go back to the hospital?
Medicare answers two separate worries here. The first is the bed. It states there is no guarantee a bed will be available for you at the same facility if you need more skilled care after the hospital stay.
Its instruction is to ask the facility whether it will hold a bed for you, and whether there is a cost to hold it. The second is your remaining days. If you re-enter the same or another skilled nursing facility within 30 days of leaving, you do not need another 3 day qualifying inpatient hospital stay to get more benefits.
The same 30 day rule applies if you simply stop getting skilled care inside the facility and then start again. The bed is not protected. The entitlement, within 30 days, is.
Can the 100 days start over?
They can, and the trigger is a long enough break rather than a new year. Medicare states that if your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your benefits, so the maximum coverage available would be up to 100 days again.
A shorter break does something different. More than 30 days without skilled care means you need a new 3 day hospital stay before you can get additional days, and Medicare notes that the new stay does not have to be for the same condition you were treated for before.
Two thresholds, two different jobs: 30 days decides whether another hospital stay is required, and 60 days decides whether the count goes back to the beginning.
Is a nursing home the same thing as a skilled nursing facility?
Not in Medicare's vocabulary, and the difference decides the coverage. Medicare files skilled nursing facility care under Part A and labels it covered, for a limited time, on a short-term basis. It files nursing home care under a page headed Not Covered, because the long-term help with daily living that many nursing homes provide sits outside the benefit.
The two overlap in the world. Medicare says plainly that many nursing homes also offer skilled nursing facility care, and that if the hospital you are in has its own facility with a bed free, you may choose to stay there.
What decides coverage is the kind of care being given and whether the facility is Medicare-certified, rather than the sign over the door.
Does a Medicare Advantage plan work the same way?
Not necessarily, and Medicare flags three places it can differ. On cost, if you are in a Medicare Advantage Plan you may be charged copayments during the first 20 days, which is the band that carries nothing per day under Original Medicare.
On the entry condition, Medicare Advantage Plans may waive the 3 day minimum inpatient hospital stay, and so may an Accountable Care Organization approved for a Skilled Nursing Facility 3-Day Rule Waiver.
On the nursing home side of the same building, Medicare says plans usually do not help pay for that care unless the home has a contract with the plan. Its instruction in every one of those cases is the same: contact your plan, and ask your doctor or hospital staff whether the stay will be covered.
