Free Guide to Medicare and TRICARE Nursing Home Coverage Options

Understanding Medicare Coverage for Nursing Home Care

Medicare is a federal health insurance program that covers people age 65 and older, some younger people with disabilities, and people with end-stage renal disease. When it comes to nursing home care, Medicare has specific rules about what it will and will not pay for. This guide explains how Medicare nursing home coverage actually works, based on information from the Centers for Medicare & Medicaid Services (CMS).

Medicare Part A is the part that covers inpatient hospital care and skilled nursing facility (SNF) care. According to CMS data, about 1.3 million people receive care in nursing homes on any given day in the United States. Of those, roughly 40% have Medicare as a primary payer for at least some of their care. However, Medicare only covers specific types of nursing home stays—not all of them.

The key requirement is that the nursing home care must be "skilled care." This means care that requires trained nurses or therapists to provide. Examples include wound care, physical therapy after surgery, management of complex medications, or care after a hospital stay. If someone needs only supervision, assistance with daily activities, or long-term custodial care, Medicare does not pay for that. According to nursing home data, about 75% of nursing home residents need custodial or non-skilled care, which Medicare does not cover.

Medicare also requires that the nursing home stay follows a hospital stay of at least 3 consecutive days (not counting the day of discharge). The person must enter the nursing home within 30 days of leaving the hospital. If these conditions are not met, Medicare will not pay. As of 2024, Medicare covers up to 100 days in a skilled nursing facility per benefit period, but beneficiaries pay different amounts depending on the day of stay.

Practical takeaway: Before assuming Medicare will pay for a nursing home stay, confirm with the hospital social worker or nursing home that the stay meets Medicare's requirements: it follows a 3-day hospital stay, the care is skilled (not custodial), and the person is admitted within 30 days of hospital discharge.

What Medicare Actually Pays and What It Does Not

Understanding the specific costs and coverage gaps in Medicare nursing home coverage is essential for planning. Medicare Part A has a cost-sharing structure that changed significantly in recent years. In 2024, for days 1–20 in a skilled nursing facility, Medicare covers all covered services with no out-of-pocket cost to the beneficiary. However, the person must have paid the Part A deductible during their hospital stay (which is $1,696 in 2024).

For days 21–100, the beneficiary pays a daily coinsurance amount. In 2024, this coinsurance is $424.00 per day. This means if someone stays 80 days, they would pay $424 per day for days 21–80, which totals $25,456 out of pocket. This is a significant expense that many people do not anticipate. After day 100, Medicare stops paying entirely, and the person or their family must cover all costs.

What is important to understand is what Medicare does not cover in a nursing home setting. Medicare does not pay for:

• Custodial care (help with bathing, dressing, eating, or toileting without a skilled nursing component)
• Long-term care or permanent residence in a nursing home
• Private duty nursing or sitters requested by the resident
• Television, telephone, or personal items
• Meals and lodging after the skilled nursing stay ends
• Care in a nursing home that is not Medicare-certified

Many nursing home residents transition from skilled care (covered by Medicare for up to 100 days) to custodial care (not covered by Medicare) while remaining in the same facility. When this transition happens, the resident or their family becomes responsible for all costs. The daily cost of nursing home care varies by region but averages about $8,821 per month for a semi-private room and $9,034 per month for a private room, according to 2023 Genworth data.

Practical takeaway: Create a written record of the daily costs you are responsible for during a nursing home stay. Days 1–20 are covered at no cost (after the hospital deductible). Days 21–100 require you to pay the daily coinsurance amount. Plan for what happens on day 101 and beyond, when Medicare stops paying entirely.

How TRICARE Covers Nursing Home and Long-Term Care

TRICARE is the health insurance program for active duty service members, retirees, survivors, and their families. Unlike Medicare, TRICARE's coverage of nursing home care varies significantly depending on the type of TRICARE plan and the beneficiary's status. Understanding these differences is critical because TRICARE rules are different from Medicare rules in several important ways.

TRICARE Prime, TRICARE Select, and TRICARE for Life each have different policies on nursing home coverage. TRICARE Prime (the HMO-style plan) generally covers inpatient skilled nursing facility care, but the beneficiary must be referred by a TRICARE provider and the facility must be TRICARE-authorized. Beneficiaries typically pay a small daily copay for SNF care under TRICARE Prime. TRICARE Select (the PPO-style plan) also covers SNF care, but beneficiaries may have higher out-of-pocket costs, including deductibles and coinsurance.

TRICARE for Life is supplemental coverage for beneficiaries age 65 and older who also have Medicare. When someone has both Medicare and TRICARE for Life, Medicare is the primary payer, and TRICARE for Life covers many of the costs that Medicare does not pay. This includes the daily coinsurance amounts for days 21–100 of skilled nursing facility care. This is a major benefit. For a TRICARE for Life beneficiary, the $424 daily coinsurance that Medicare does not cover is typically covered by TRICARE for Life.

One important limitation: TRICARE generally does not cover long-term custodial nursing home care the way it covers skilled nursing care. If the nursing home stay extends beyond the skilled care phase, TRICARE will not pay for custodial care. Some TRICARE beneficiaries, particularly retirees and their families, may be able to explore other options through the VA (Department of Veterans Affairs) if they are veterans, but this requires separate verification.

Practical takeaway: If you have TRICARE, contact your TRICARE region or call the TRICARE customer service line (1-800-874-2273) before a nursing home stay to confirm which facilities are TRICARE-authorized and what your out-of-pocket costs will be. If you are 65 or older and have TRICARE for Life, ask specifically whether your SNF coinsurance will be covered.

How Medicare and TRICARE Work Together When You Have Both

Many military retirees and beneficiaries age 65 and older have both Medicare and TRICARE. When a person has two insurance plans, understanding which plan pays first (primary) and which pays second (secondary) is essential. This process is called "coordination of benefits," and it determines how much you pay out of pocket.

For people with both Medicare and TRICARE, Medicare is always the primary payer. This means Medicare processes the claim first and pays according to Medicare rules. TRICARE then acts as secondary insurance and may pay for costs that Medicare does not cover. For skilled nursing facility care, this coordination works as follows:

• The SNF bills Medicare first for the covered skilled care
• Medicare pays its portion according to its rules (covers days 1–20 fully, then beneficiary owes coinsurance days 21–100)
• The bill then goes to TRICARE, which may pay the coinsurance amounts that Medicare did not pay
• The beneficiary may owe nothing out of pocket if TRICARE covers the Medicare coinsurance

This coordination benefit is one reason why TRICARE for Life is valuable for military retirees over 65. Without TRICARE for Life as secondary coverage, a beneficiary with only Medicare would owe the daily coinsurance for days 21–100 out of pocket