What Happens When Medicare Stops Paying for Nursing Home Care?

Understanding what happens when Medicare stops paying for nursing home care is critical for families navigating long-term care decisions. Medicare’s nursing home benefit is far more limited than most people expect, and when that coverage window closes the financial burden can shift dramatically. Knowing your options in advance can turn a crisis into a manageable plan. If you or a loved one relies on skilled nursing facility care, learning what happens when Medicare stops paying — and what to do next — will help you protect your family’s finances and your loved one’s care.

How Medicare Covers Nursing Home Care

Medicare Part A covers skilled nursing facility (SNF) care only under specific conditions, and only for a limited time. According to Medicare.gov and the Centers for Medicare & Medicaid Services (CMS), you generally must meet all of the following criteria to qualify:

• A qualifying inpatient hospital stay of at least three consecutive days (the day of discharge and any outpatient or observation days do not count).
• Admission to a Medicare-certified skilled nursing facility, generally within 30 days of that hospital stay.
• A doctor’s determination that you need daily skilled care — skilled nursing or skilled therapy such as physical, occupational, or speech therapy — that can only be provided in a SNF.
• Care for a condition treated during your qualifying hospital stay, or a condition that arose while you were getting SNF care.

When these conditions are met, Medicare covers a SNF stay for up to 100 days per benefit period — and no more. The cost-sharing is tiered:

• Days 1–20: Medicare pays the full cost of covered services. You pay nothing per day (after any Part A hospital deductible for the related stay, which is $1,736 in 2026).
• Days 21–100: You pay a daily coinsurance. For 2026 this amount is about $217 per day. These figures are set by CMS every year, so always confirm the current amount at Medicare.gov or by calling 1-800-MEDICARE.
• After day 100: Medicare pays nothing. You are responsible for all costs.

It is worth repeating the single most misunderstood fact about this benefit: Medicare does not pay for long-term or custodial nursing home care. It covers short-term skilled care during recovery, not indefinite room-and-board and help with daily living.

Why Medicare Coverage Often Ends Before Day 100

Many families assume they will automatically receive the full 100 days, but Medicare frequently stops paying well before that mark. Coverage ends when the facility or Medicare determines that you no longer need daily skilled care. Common reasons include:

• Skilled need ends: Once your medical situation stabilizes and you no longer require daily skilled nursing or therapy, Medicare’s SNF benefit stops — even if you still need a great deal of help.
• Transition to custodial care: When your needs shift to help with activities of daily living — bathing, dressing, eating, moving — Medicare classifies this as custodial care, which it does not cover.
• Missed or refused therapy: If a resident cannot or will not participate in prescribed therapy, the facility may report that skilled care is no longer being delivered.

Medicare-covered SNF stays are typically much shorter than the 100-day maximum — analyses of Medicare data have long shown average covered stays running only a few weeks. That is why it is so important to understand the rules before you assume coverage will continue.

Important: The “Improvement Standard” Is Not the Law

For years, families were wrongly told that Medicare would only keep paying if the patient was improving. That is not the rule. Under the Jimmo v. Sebelius settlement (finalized in 2013, with CMS re-issuing clarifying guidance in the years since), coverage of skilled care does not depend on the potential for improvement. Skilled care can be covered when it is needed to maintain the patient’s condition or to prevent or slow decline, as long as the care itself requires the skills of professional staff and meets the other coverage rules.

This matters enormously. If a facility tells you Medicare is cutting off coverage because your loved one has “plateaued” or “stopped improving,” that reason alone may be an improper application of the improvement standard. You can and should appeal. Ask the treatment team to document why skilled care is still medically necessary to maintain function or prevent deterioration. CMS resources and the Center for Medicare Advocacy explain the Jimmo standard in detail.

What Happens the Moment Medicare Coverage Ends

When Medicare is about to stop paying, you should receive a written notice. For an expected end of covered services you typically get a Notice of Medicare Non-Coverage (NOMNC) at least two days before coverage ends, and the facility may issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) explaining that Medicare may not pay and outlining your financial responsibility. Here is what typically happens next.

You Become Responsible for the Full Cost

Nursing home costs vary widely by state and facility, but they are high everywhere. Recent editions of the Genworth/CareScout Cost of Care Survey put the national median for a semi-private room in the low-to-mid thousands per month — on the order of $9,000 or more — and private rooms higher still. Actual prices differ significantly by region, so treat any single figure as an estimate and verify current local costs. Without Medicare coverage, these amounts come out of pocket unless another payer steps in.

The Facility May Begin Discharge Planning

If you cannot pay privately, the nursing home may begin discharge planning — but it must follow federal law. Under the Nursing Home Reform Act, the facility generally must give at least 30 days’ written notice before an involuntary discharge, cannot discharge you to an unsafe setting, and must help arrange an appropriate alternative such as home health care or transfer to another facility. You also have the right to appeal a discharge to your state’s long-term care ombudsman and Medicaid agency.

You May Need to Apply for Medicaid

Medicaid — not Medicare — is the primary payer for long-term nursing home care in the United States. Unlike Medicare, Medicaid covers custodial care for people who meet its financial and functional eligibility rules. Those rules include strict income and asset limits that vary by state; in many states a single applicant can have no more than about $2,000 in countable assets, though a home, one vehicle, and certain other assets may be exempt. Medicaid also uses a five-year look-back at asset transfers, which can create penalty periods if assets were given away to qualify.

Your Options After Medicare Stops Paying

When Medicare coverage ends, you generally have several pathways to consider. Each has different financial implications and eligibility requirements, and many families combine more than one.

Private Pay

If you have savings, retirement accounts, pension and Social Security income, or other assets, you can pay the nursing home directly. Many families blend several income sources to cover the bill. But at several thousand dollars a month, private pay can deplete a lifetime of savings quickly, which is why planning ahead matters so much.

Long-Term Care Insurance

If your loved one purchased a long-term care insurance policy before needing care, it may cover part of the cost. Benefits vary widely — daily benefit amounts, elimination (waiting) periods, inflation riders, and lifetime caps all differ by policy. Read the policy carefully, note the elimination period so you know how long you must pay before benefits start, and consider consulting an insurance specialist.

Medicaid Coverage

Medicaid is the most common funding source for long-term nursing home stays. To qualify, you must meet your state’s income and asset criteria and demonstrate a functional need for nursing-facility level care. The application process can take several weeks to a few months, so it is wise to begin before Medicare coverage ends. Many states have elder law and Medicaid-planning attorneys who can help you structure assets legally within the rules — and steer clear of transfers that trigger look-back penalties.

Veterans Benefits

Wartime veterans and surviving spouses may qualify for the VA Aid and Attendance benefit, which adds a monthly amount to a VA pension to help cover nursing home, assisted living, or in-home care. Eligibility depends on service history, care needs, and financial limits. Check VA.gov or speak with an accredited VA benefits representative.

Appeal the Medicare Decision

You have the right to appeal if you believe Medicare stopped paying prematurely — and, as noted above, “no longer improving” is not by itself a valid reason to end skilled coverage. Appeals can be worth pursuing when your medical team believes skilled care is still needed.

How to Appeal a Medicare Nursing Home Coverage Decision

Here is how the appeals process generally works:

1. Request a fast (expedited) appeal: When you receive the Notice of Medicare Non-Coverage, you can ask a Quality Improvement Organization (QIO) for an immediate review. You generally must request it by noon of the day after you receive the notice. If you file on time, coverage typically continues while the QIO decides, and you usually are not charged for the disputed days while the fast appeal is pending.
2. File a standard appeal if you miss the fast deadline: You can request a standard redetermination from your Medicare Administrative Contractor, generally within 120 days of the Medicare Summary Notice (MSN) or the relevant coverage decision.
3. Gather supporting documentation: Ask the doctor, therapist, and nursing staff for written statements explaining why skilled care remains medically necessary — including to maintain function or prevent decline under the Jimmo standard.
4. Escalate through the levels if needed: Medicare appeals have five levels — redetermination, reconsideration by a Qualified Independent Contractor, an Administrative Law Judge hearing, review by the Medicare Appeals Council, and finally federal court review.

Appeals are not guaranteed to succeed, but beneficiaries do win a meaningful share of SNF denial appeals, especially when the record clearly documents an ongoing skilled need. When care is clinically justified, an appeal is often worth the effort.

Planning Ahead: How to Prepare Before Medicare Ends

The best time to plan for what happens when Medicare stops paying is before a nursing home is ever needed. But even if coverage is ending soon, these steps can help:

• Talk to the facility social worker or discharge planner: Every nursing home has staff whose job is to help you understand options and connect with community resources.
• Start Medicaid planning early: Because of the five-year look-back on asset transfers, last-minute moves can backfire. Consult an elder law attorney to understand what is allowed in your state.
• Explore home health care: Medicare may cover home health care even after SNF benefits end. If your loved one can safely return home with visiting nurses and therapists, this can be a cost-effective alternative.
• Know your rights: Nursing home residents have federal protections under the Nursing Home Reform Act, including protection from improper discharge and the right to appeal.
• Review supplemental insurance: Some Medigap policies (including Plans C and F for those eligible before 2020, and Plans that cover SNF coinsurance) help pay the days 21–100 coinsurance, which can save thousands of dollars.
• Contact your State Health Insurance Assistance Program (SHIP): SHIP counselors offer free, unbiased help understanding Medicare, Medicaid, and appeals.

Frequently Asked Questions

Does Medicare ever pay for long-term nursing home care?

No. Medicare only covers short-term skilled nursing facility care — up to 100 days per benefit period, and only while daily skilled care is needed. It does not pay for long-term custodial care (help with activities of daily living such as bathing, dressing, and eating). For long-term coverage, Medicaid is the primary option for those who qualify financially. For a deeper look at coverage rules, visit our policy guide.

Can a nursing home force you to leave if Medicare stops paying?

A nursing home can begin discharge proceedings, but it must follow federal rules. The facility generally must provide at least 30 days’ written notice, arrange a safe alternative, and honor your right to appeal the discharge. You cannot lawfully be put out on the street or sent somewhere unsafe.

How do I qualify for Medicaid to pay for nursing home care?

Medicaid eligibility varies by state but generally requires that your income and countable assets fall below set limits — often around $2,000 in countable assets for a single applicant, with a home, one vehicle, and certain other assets potentially exempt. A five-year look-back applies to asset transfers. An elder law attorney can help you navigate the rules legally.

What is the difference between skilled care and custodial care?

Skilled care requires licensed professionals — registered nurses or physical, occupational, or speech therapists — and includes services like wound care, IV therapy, and rehabilitation. Custodial care is help with daily activities and does not require medical training. Medicare covers skilled care; it does not cover custodial care.

Can I get a new 100-day Medicare benefit period?

Yes. A new benefit period begins after you have been out of a hospital and out of a skilled nursing facility for at least 60 consecutive days. If you are later readmitted to the hospital for a qualifying stay after that gap, you may qualify for a new 100-day SNF benefit period.

What if Medicare is ending coverage because my loved one “stopped improving”?

That reason alone is not a valid basis to end skilled coverage. Under the Jimmo v. Sebelius settlement, skilled care can be covered to maintain function or prevent decline, not only to improve. Ask the care team to document the ongoing skilled need and file an expedited appeal.

Sources

• Medicare.gov — Skilled nursing facility (SNF) care coverage and 2026 costs
• CMS.gov — Jimmo v. Sebelius settlement and skilled-care coverage guidance; Medicare appeals process
• Medicaid.gov — Long-term care eligibility, income/asset limits, and the five-year look-back
• Genworth / CareScout Cost of Care Survey — National and state nursing home cost estimates
• VA.gov — Aid and Attendance and Housebound benefits
• Center for Medicare Advocacy — Jimmo standard and SNF coverage/appeals resources