Did you know that Original Medicare covers skilled nursing facility care 100%? It is true after a qualifying 3-day inpatient hospital stay and doctor’s order Original Medicare covers a member in full in skilled nursing care for up to 20 days. If you or a loved one is still in skilled nursing by day 21 a member’s Medicare Supplement or Medigap plan takes over from Original Medicare to cover this cost which is $217 a day (2026). Once you reach 100 days in a skilled nursing facility this benefit runs out and it does not renew unless you have avoided being in the hospital or in a skilled nursing facility for 60 consecutive days
However, if you have a Medicare Advantage plan, the qualifying 3 -day inpatient hospital stay usually does not apply but a member must get pre-authorization from their insurer through their doctor for skilled nursing care, and the facility must be in the plan’s network. After 20 days Original Medicare stops paying then the Medicare Advantage member is then responsible for a daily copay on day 21 up to the maximum 100 days in a skilled nursing facility. The exception to this is if the member has met the annual deductible for their Medicare Advantage plan in which case the plan pays in full.
Are there insurance plans I can purchase just in case I may need skilled nursing care or another type for home or skilled nursing care to help with the costs? Yes, there are and we offer them at Santo Family Insurance, LLC.
A short-term recovery care plan lets a member choose a set period no longer than 360 days (lifetime benefit) to be reimbursed for home care, assisted living care or skilled nursing care. These policies generally have simplified underwriting and have two requirements to become active. First the waiting period must be met and the second a member must not be able to perform 2 or more activities of daily living. Once the benefit period ends, the short-term care plan expires.
The other option is a long-term care policy which has a policy range of 2-5 years depending on the insurance carrier before expiration of the policy. It is best to apply for a long-term care policy when you are between 50 and 65 years of age. Eligibility is determined by full medical underwriting. The policy does not go into effect immediately. A doctor must confirm you or someone you love meets certain medical criteria, not just the inability to perform activities of daily living.
One more option is if you are a veteran, a surviving spouse of a veteran, or two married veterans, you can contact the Veterans Administration and see if you qualify for the VA Aid and Attendance Program. If eligible and approved, the program adds a monetary benefit to a standard VA pension or disability compensation, which can then be used to pay for home care, assisted living help, or nursing home care.
However, there might still be ways to help pay for care without straining personal finances, retirement funds, spending cash value in a whole or universal life policy or going bankrupt. For instance, a Medicaid lawyer may help you form a trust so you or your spouse could be eligible for Medicaid without spending down to meet eligibility requirements. Or there are investments like a Medicaid-compliant annuity that can convert countable assets into a non-countable income stream. Everyone’s situation is different, and not all the options mentioned previously are available to everyone. If you would like to discuss your situation for guidance about what is available to you, please reach out to us by phone, online contact form, or email today. Do not hesitate, as time may be of the essence.
Photo by Centre for Ageing Better on Unsplash