Does Medicare or Medicaid Cover Nursing Homes in Pennsylvania?

When it comes to paying for nursing home care, many families in Pennsylvania turn to Medicare or Medicaid.

Both of these government programs can help with nursing home costs, but they have specific eligibility requirements and coverage options that vary.

Understanding how Medicare and Medicaid work, what they cover, and how to qualify can help you make an informed decision about long-term care for your loved one.

What is Medicare?

Medicare is a federal health insurance program primarily for people over 65 and those with certain disabilities. It covers a wide range of health services, but when it comes to nursing homes, the coverage is limited. Original Medicare (Parts A and B) offers limited nursing home care coverage, and there are specific requirements you must meet to qualify for it.

Medicare Coverage for Nursing Homes

• Skilled Nursing Facility (SNF) Care: Medicare covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions. Medicare only covers a skilled nursing facility stay after a hospital stay of at least three days. This coverage is for a short-term stay (up to 100 days) for rehabilitation or medical care following surgery, illness, or injury.
• First 20 Days: If you’re eligible, Medicare will cover 100% of the costs of your stay in a skilled nursing facility for the first 20 days, provided that the care is medically necessary.
• Days 21-100: For days 21 through 100, Medicare pays a portion of the costs (the amount covered varies depending on the facility and location). You will need to pay a daily co-payment, which in 2025 is expected to be about $200 per day for skilled nursing care.
• After 100 Days: Once you’ve reached day 101, Medicare stops covering the costs of your nursing home stay, and you’ll have to pay for it out of pocket or through other means, such as Medicaid.

What Medicare Does NOT Cover

While Medicare provides coverage for skilled nursing care under the circumstances mentioned above, it does not cover long-term custodial care in a nursing home.

If your loved one requires long-term care for chronic conditions or needs help with activities of daily living (ADLs) such as bathing, dressing, or eating, Medicare will not cover those costs after the 100-day limit. Medicare does not cover personal care or the cost of a private room unless medically necessary.

What is Medicaid?

Medicaid, unlike Medicare, is a joint federal and state program that provides healthcare coverage for low-income individuals, including nursing home care. The program is designed to assist people who cannot afford the high costs of long-term care.

In Pennsylvania, Medicaid can help pay for nursing home care if you meet certain eligibility requirements. Since Medicaid is managed by each state, the specifics of the program can vary from state to state.

In Pennsylvania, Medicaid programs can cover a variety of long-term care services, including nursing home costs, as long as the individual meets financial and medical eligibility requirements.

Medicaid Coverage for Nursing Homes

• Medicaid Covers Nursing Home Care: Medicaid will cover the costs of a room in a nursing home, including skilled nursing care, and may also cover a private room if it is deemed medically necessary. Medicaid coverage includes both medical care and long-term custodial care for individuals who need help with ADLs and have chronic conditions requiring ongoing supervision.
• Long-Term Care: Medicaid is the primary program that helps cover long-term care services, including care in a skilled nursing facility. Unlike Medicare, which limits coverage to short-term stays, Medicaid pays for as long as necessary, based on eligibility.
• Eligibility for Medicaid: To qualify for Medicaid, you must meet income and asset requirements. Each state, including Pennsylvania, sets its own income limits, which can vary. For example, in Pennsylvania, individuals typically need to have a monthly income below a certain threshold to qualify for Medicaid. The specific amount can change from year to year, so it’s important to check current eligibility requirements.

Medicaid Eligibility Requirements

The eligibility requirements for Medicaid in Pennsylvania are based on both income and assets:

• Income Limits: Medicaid has strict income limits, which include earnings, Social Security benefits, and pensions. For an individual to qualify for Medicaid, their income must be below a certain level. This level may be higher for married couples, and there are different limits for people applying for long-term care.
• Asset Limits: Medicaid also has limits on the amount of assets you can have to qualify. In Pennsylvania, the asset limit for an individual is typically around $2,000, although the home, car, and personal belongings are generally not counted toward this limit.
• Spending Down Assets: If you have too many assets to qualify for Medicaid, you may need to “spend down” your assets to meet the eligibility requirements. This could include paying down debt, purchasing necessary goods, or using your savings to pay for medical or care services until you meet the Medicaid eligibility threshold.
• Medically Needy Pathway: In some cases, people who do not meet the income limits may still be able to qualify for Medicaid if their medical expenses are high enough to qualify them under Pennsylvania’s medically needy pathway.

How to Pay for Nursing Home Care in Pennsylvania

For those who qualify for Medicaid, the program will help cover the costs of nursing home care. However, if you do not qualify for Medicaid or if you need care beyond what Medicare or Medicaid covers, there are other ways to pay for nursing home care in Pennsylvania:

• Private Pay: If you have sufficient income and savings, you may need to pay for nursing homes out of pocket. The costs of nursing for a private room can be significant, with expenses ranging from $8,000 to $10,000 per month, depending on the facility and location.
• Long-Term Care Insurance: Some people invest in long-term care insurance, which can help cover the costs of nursing home care. This insurance is typically purchased in advance and can provide a way to offset the costs of care that Medicare and Medicaid do not cover.
• Veterans Benefits: If your family member is a veteran, they may be eligible for additional benefits to help pay for nursing home care. The Department of Veterans Affairs offers a variety of programs to assist veterans with long-term care needs.

Applying for Medicaid

If you think your loved one may be eligible for Medicaid, the next step is to apply. In Pennsylvania, you can apply for Medicaid through the Department of Human Services. You’ll need to provide documentation of income, assets, and medical needs, as well as other personal information.

Once your application is submitted, the state will assess your eligibility based on current guidelines. If approved, Medicaid can begin covering your loved one’s nursing home costs, including skilled nursing and custodial care, as well as a private room if needed.

In Pennsylvania, both Medicare and Medicaid offer coverage for nursing home care, but the extent of that coverage and the eligibility requirements vary.

Medicare primarily covers short-term care in skilled nursing facilities, while Medicaid provides more comprehensive coverage for long-term care, including room and board in nursing homes.

Understanding the cost of care, how to qualify for Medicaid, and what services are covered can help families make informed decisions when planning for long-term care.

Whether you need help with a shared room or private room, or you’re looking for financial assistance through Medicaid programs, it’s essential to know your options to ensure your loved one receives the best possible care.