Paying for nursing home care

Payment rules change, and individual eligibility is fact-specific. What follows is a conservative outline of how the major sources usually work. Confirm current rules on Medicare.gov and Texas Medicaid, or with a discharge planner, before you rely on them.

Medicare (short-term skilled nursing)

Medicare Part A may cover a limited skilled nursing facility (SNF) stay after a qualifying hospital inpatient stay, when the person needs daily skilled nursing or rehabilitation and the facility is Medicare-certified. CMS has long applied a three-day inpatient hospital requirement for a traditional Medicare SNF benefit; some Medicare Advantage plans use different rules. Always confirm the current requirement for the person’s coverage.

Under traditional Medicare, coverage — when it applies — has historically been structured as a limited benefit period (commonly described as up to 100 days), with days 1–20 often paid in full by Medicare and later days requiring a coinsurance amount set each year. After the covered SNF benefit is exhausted, Medicare does not pay for continuing custodial nursing home care. Amounts and conditions are set by CMS and should be verified for the current year on Medicare.gov.

Medicare Advantage plans must cover at least the same SNF benefit category, but prior authorization, networks, and cost sharing can differ. Ask the plan in writing.

Medicaid (long-term care, if eligible)

Texas Medicaid can pay for long-term nursing facility care for people who meet both clinical and financial eligibility rules. Those rules are administered by the state and can include income and resource limits, a medical necessity determination, and, for a married couple, spousal-impoverishment protections. Application and screening run through HHSC. This site does not determine eligibility.

Private payment and insurance

Many stays begin as private pay or as a short Medicare stay and later change payer. Long-term care insurance, veterans’ benefits, and family funds are other sources. Ask the facility, in writing, what is included in the daily rate, what happens when a Medicare stay ends, and whether a Medicaid bed would be available if eligibility is later approved.

This page is general information, not legal, financial, or medical advice, and not a promise of coverage. Rules cited here should be checked against official publications current as of the date you need them.