What Happens When Medicare Stops Paying for Nursing Home Care?

If you or a loved one has been receiving care in a nursing home under Medicare coverage, you may be facing a challenging transition. It's a situation many families find themselves in, often with little warning or preparation.

Medicare's coverage of nursing home care—officially called skilled nursing facility (SNF) care—is quite limited. This comes as a surprise to many people who assume Medicare will cover all their healthcare needs in retirement.

Medicare only pays for nursing home care under specific circumstances and for a limited time. To qualify for Medicare coverage in a nursing home, you must:

• Have Medicare Part A (hospital insurance)
• Have days left in your benefit period
• Have a qualifying hospital stay of at least 3 consecutive days
• Need skilled nursing or rehabilitation services on a daily basis
• Have these services ordered by a doctor
• Receive these services for a condition related to your hospital stay

Even when all these conditions are met, Medicare coverage is temporary. Medicare covers up to 100 days of skilled nursing care per benefit period, with full coverage only for the first 20 days. For days 21-100, you pay a daily coinsurance ($204 per day in 2025).

After day 100, Medicare stops paying completely.

Signs That Medicare Coverage Is Ending for Nursing Home Care

The nursing home staff and social workers should inform you when Medicare coverage is nearing its end. You might receive:

• A written "Notice of Medicare Non-Coverage" that states when Medicare coverage will end
• An explanation of your right to appeal this decision if you believe coverage should continue
• Information about your financial responsibility going forward

If you believe Medicare coverage is ending prematurely because skilled nursing care is still medically necessary, you have the right to appeal.

The notice you receive will include instructions for contacting the Beneficiary and Family Centered Care Quality Improvement Organization in your state to request an expedited appeal.

Financial Options When Medicare Stops Paying for Nursing Home Care

When Medicare coverage ends, nursing home care doesn't suddenly become less expensive—the cost simply shifts to other payers. The average cost of nursing home care in 2025 is approximately $10,965 per month for a private room, according to the Genworth Cost of Care Survey.

Here are your primary options for covering these costs:

Private Pay

Using personal resources is the most straightforward option, though certainly not the easiest financially. This might include:

• Savings and retirement accounts
• Income from Social Security, pensions, or investments
• Proceeds from selling a home
• Contributions from family members

For many families, private paying is a temporary bridge while applying for other assistance programs.

Long-Term Care Insurance

If you or your loved one has a long-term care insurance policy, now is the time to activate it. These policies typically cover nursing home care, though benefits vary significantly between policies.

Contact the insurance company promptly to:

• Verify eligibility requirements (many policies have elimination periods)
• Understand what documentation you need to submit
• Confirm coverage amounts and duration
• Learn about any exclusions that might apply

Veterans Benefits

Veterans and surviving spouses may qualify for Long Term Care benefits through the Department of Veterans Affairs (VA). The Aid and Attendance benefit can provide additional monthly pension to help pay for nursing home care.

Eligibility depends on military service records, medical needs, and financial situation. Contact your regional VA office or a VA-accredited representative to explore these benefits.

Medicaid

For many Americans, Medicaid becomes the primary payer for long-term nursing home care when personal resources are depleted. Medicaid is a joint federal and state program that covers nursing home care for those who meet financial eligibility requirements.

Unlike Medicare, Medicaid can cover long-term care indefinitely for those who qualify. However, qualifying for Medicaid requires having limited income and assets, which vary by state.

Transitioning to Medicaid Coverage for Nursing Home Coverage

For many families, transitioning to Medicaid becomes necessary when Medicare coverage ends and personal resources are insufficient for long-term care.

Medicaid Eligibility

Medicaid eligibility is complex and varies by state, but generally considers:

• Monthly income limits
• Asset limits (with certain exemptions)
• Look-back periods for asset transfers (typically 5 years)

In 2025, most states allow nursing home residents to have no more than $2,000-$3,000 in countable assets as an individual, or somewhat more for couples when one spouse remains in the community.

Some assets may be exempt, including:

• A primary residence (in many cases, subject to equity limits)
• One vehicle
• Personal belongings and household items
• Certain burial funds or prepaid funeral arrangements
• Some retirement accounts (varies by state)

Applying for Medicaid

The Medicaid application process can be lengthy and requires extensive documentation. To prepare:

• Start gathering financial records for the past five years, including bank statements, investment accounts, property deeds, and insurance policies. This thorough documentation is necessary because Medicaid will review financial transactions during the "look-back period" to ensure no assets were transferred or sold below market value specifically to qualify for benefits.
• Consult with an elder law attorney who specializes in Medicaid planning. While this involves an upfront cost, their expertise can often save considerable money and stress in the long run. They can help identify allowable spend-down strategies and ensure the application is complete.
• Contact your state's Medicaid office or your local Area Agency on Aging for application assistance. Many areas have Medicaid counselors who can guide you through the process at no cost.
• Be prepared for a potentially lengthy determination process, which can take between 45-90 days in most states. Having alternative payment arrangements during this waiting period is essential.

Preparing for Loss of Medicare Coverage

The most stressful transitions occur when families are caught unprepared as Medicare coverage ends. Here are steps to take as early as possible:

Have the Financial Conversation Early

As soon as a loved one enters a nursing home under Medicare, start planning for what happens after those 100 days. The social services department at the nursing home can often provide estimates of ongoing costs and help you understand payment options.

Consider Medicaid Planning in Advance

If Medicaid might be needed eventually, consulting with an elder law attorney sooner rather than later can preserve more options. Proper planning—done well before a crisis—can help protect some assets while still qualifying for benefits.

Research Facility Policies

Understand whether the current nursing home accepts other payment sources and what their policies are regarding transitions from Medicare to private pay or Medicaid.

Explore Community Resources

Many communities have programs that might help bridge gaps or provide supplemental services:

• Area Agencies on Aging can connect you with local resources
• Non-profit organizations sometimes offer financial assistance
• Some states have programs to help seniors remain in the least restrictive environment possible

Advocating for Your Loved One When Medicare Stops Paying for Nursing Home Care

Payment transitions can be stressful, not just financially but emotionally. Here's how to advocate effectively:

Know Your Rights

Nursing homes cannot abruptly discharge residents when their payment source changes. Federal regulations require appropriate notice (usually 30 days) and a safe discharge plan.

If you feel a facility is handling the transition inappropriately, contact your state's long-term care ombudsman. Additionally, utilizing the support of a healthcare advocate, such as the ones found at Pinnie, can be helpful to bring you up to speed on how to navigate nursing home care.

Maintain Communication

Keep open lines of communication with the nursing home's social services and billing departments. Ask questions about anything you don't understand and request written explanations of changes.

Focus on Continuity of Care

During payment transitions, make sure the care plan remains appropriate and is being followed.

Attend care plan meetings and document any changes in care quality.

Prepare for Emotional Impacts

Payment transitions often coincide with difficult realizations about long-term care needs. Both you and your loved one may need emotional support during this time. Consider:

• Joining a caregiver support group
• Speaking with a counselor or healthcare advocate familiar with elder care issues
• Connecting with faith-based support services if applicable

Bottom Line

The end of Medicare coverage for nursing home care represents a significant transition, but with preparation and knowledge of your options, it doesn't have to be a crisis.

Understanding the limitations of Medicare coverage from the beginning, exploring all payment options, and planning ahead can help ensure continuous quality care for your loved one while protecting your family's financial well-being as much as possible.

Utilizing support resources and experienced healthcare professionals, such as healthcare advocates (such as the ones at Pinnie) can save time and reduce stress.