Medicare vs Medicaid: What’s the Difference?

Medicare and Skilled Nursing Facilities

Medicare can be a valuable resource for older adults who need short-term rehabilitation care in a skilled nursing facility (SNF), especially after a hospital stay. However, it’s important to understand the limitations of Medicare coverage, as it does not usually pay for custodial long-term care.

What Does Medicare Cover in a Skilled Nursing Facility?

Medicare Part A (sometimes called Hospital Insurance) covers short-term skilled nursing care, as long as it comes after a qualifying hospital stay. Coverage typically includes:

• A semi-private room
• Meals
• Physical, occupational, or speech therapy as required
• Medical supplies, medications, and equipment used in the facility
• Ambulance transportation (if medically necessary)
• Dietary counseling

Generally, Medicare SNF coverage is designed for short-term rehab and recovery, not permanent residence in a nursing home.

Eligibility Requirements for Medicare Skilled Nursing Coverage

To qualify for Medicare to cover care in a skilled nursing facility: 

• You must have Medicare Part A and have days remaining in your benefit period
• You had a qualifying inpatient hospital stay of at least three consecutive days (not including your discharge day)
• A doctor has ordered skilled nursing or therapy services
• You need services that are provided daily and can only be given in a skilled nursing facility
• The SNF is Medicare-certified
  
  

What Is a Medicare Benefit Period?

A Medicare benefit period, also known as a “spell of illness”, is a way Medicare measures your use of skilled nursing facility services. A benefit period begins on the day you’re admitted as an inpatient and ends when you haven’t been in a hospital or SNF for 60 consecutive days. There’s no limit to how many benefit periods you can have in your lifetime.

How Long Does Medicare Cover Skilled Nursing Facility Care?

Medicare provides limited coverage under Part A, based on the length of your stay in the skilled nursing facility:

• Days 1–20: 100% of covered services are paid by Medicare
• Days 21–100: You pay a daily coinsurance and Medicare covers the rest
• After Day 100: Medicare stops paying, and you are responsible for all costs
  
  

Medicare coverage is limited to 100 days per benefit period, and only if ongoing skilled care is still needed. 

What Happens When Medicare Coverage Ends?

If you or your loved one still needs care after Medicare coverage runs out, you may need to:

• Pay privately (out-of-pocket)
• Apply for Medicaid, if eligible
• Consider long-term care insurance, if available
• Discuss with the facility about financial planning or alternate payor sources
  
  

Remember, your Medicare benefits effectively “reset” if you start a new benefit period. So, if you go 60 days without hospital or SNF care, then have another qualifying hospital stay, you’ll have another 100 days of Medicare SNF coverage.

What Medicare Does Not Cover in Skilled Nursing Facilities

It’s also important to understand what Medicare does not cover, including:

• Long-term custodial care (e.g., help with bathing, dressing, eating) when skilled care is no longer needed
• Private rooms (unless medically necessary)
• Personal items (like TV, phone, or toiletries)
  
  

In general, services not considered “medically necessary” aren’t covered under Medicare. 

Medicaid and Skilled Nursing Facilities 

While Medicare coverage focuses on short-term rehab in an SNF, Medicaid is mostly used for long-term care in these facilities. If a resident needs ongoing help with daily activities or can’t pay privately, they often rely on Medicaid.

What Does Medicaid Cover in a Skilled Nursing Facility?

For eligible residents in SNFs, Medicaid usually covers:

• 24-hour care
• Room and board
• Help with bathing, dressing, and eating
• Medical equipment, prescription medications, and medical supplies
• Physical, occupational, and speech therapies (if needed)
• Some social events and activities
• Transportation to medical appointments (coverage varies by state)
  
  

Eligibility Requirements for Medicaid Long-Term Care

To qualify for Medicaid, you must meet both financial and medical criteria. Usually, your monthly income must be below a state-defined threshold, and your countable assets are typically limited to $2,000 or less (for an individual). 

Some assets (like a primary residence, vehicle, and personal belongings) may be exempt, and spouses can sometimes keep a portion of their partner’s assets and income, under “spousal impoverishment protections.”

To confirm medical eligibility, a medical evaluation is generally required by the state, with each state having their own qualifiers. In general, the patient must demonstrate a need for skilled nursing care and require help with multiple activities of daily living, such as mobility, bathing, or feeding. 

How Medicaid Helps Pay for Long-Term Care

If approved, Medicaid covers the full cost of room, board, and care at a certified facility. In most cases, residents contribute most of their monthly income to the cost of care, and Medicaid pays the remainder. A personal needs allowance is usually set aside each month for personal expenses like clothing.

How to Apply for Medicaid Long-Term Care

Applying for Medicaid can be complex, but many SNFs provide application support or can refer you to law professionals experienced in the field. In general, you’ll need to:

• Compile your financial documents, like bank statements, income sources, and property deeds
• Complete a state Medicaid application, either online or through your local office
• Undergo a medical assessment, if required
  
  

Once your application is complete, you’ll need to wait to see the outcome. Timelines vary from state to state, but the approval process generally takes several weeks. 

When Medicaid Coverage Begins

Medicaid coverage can begin retroactively for up to 3 months before the application date (if the individual was eligible), or as soon as the individual is approved and admitted to a Medicaid-certified skilled nursing facility. 

Contact Nightingale to Learn More

At Nightingale, our goal is to make healthcare more accessible. We know it can be confusing and frustrating to understand Medicare vs Medicaid, and our team always strives to ensure your or your family member’s care is as seamless as possible. We work with Medicare, Medicaid, HMO plans, and many other payment providers.