Medicare and skilled nursing facility coverage — the 100-day reality

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

My mother had been in the skilled nursing facility for 87 days. She was doing better. The physical therapist said she was making steady progress. Her stroke recovery was progressing as expected. Her medications were stable. Everything seemed to be moving forward.

Then the facility administrator called me. "Your mother is approaching day 100," he said. "Her Medicare coverage for skilled care ends on day 100. She'll need to transition to self-pay or Medicaid after that."

I did the math quickly. She was improving, but not dramatically. The therapist had said recovery from stroke takes time—sometimes months. She couldn't walk without a walker. She couldn't manage stairs. She couldn't live alone. By day 100, she would be better than day three, when she arrived, but she wouldn't be recovered.

That's when I learned that Medicare covers 100 days of skilled nursing facility care, and that 100-day limit is real. It's not extended for people who aren't finished recovering. It's not waived for people doing well. It ends at day 100, and what happens next becomes your problem.

This is one of the most misunderstood pieces of Medicare. Families think Medicare covers nursing home care. It covers skilled nursing facility care, which is a specific type of rehabilitation care, and it covers it for 100 days maximum. After that, it stops.

What Qualifies as Skilled Nursing Facility Care

A skilled nursing facility is not just any nursing home. It's a specific type of facility providing a specific type of care that Medicare will pay for.

Your parent qualifies for skilled nursing facility care if they need skilled care—care that requires judgment, assessment, and professional intervention by a nurse. This includes wound care, medication management, catheter care, intravenous therapy, or observation for medical complications. Your parent needs care that only a licensed nurse can provide, not just supervision or assistance.

Your parent also needs to be rehabilitating toward a goal. Physical therapy aimed at restoring walking ability, occupational therapy aimed at restoring self-care ability, speech therapy aimed at restoring swallowing ability,these are the services that define skilled nursing facility care. Your parent isn't just being housed and fed. Your parent is receiving rehabilitation.

This is the distinction that separates skilled nursing facility care from custodial nursing home care. In a custodial setting, your parent gets help with daily living and medication supervision. In a skilled nursing facility, your parent gets skilled nursing care plus intensive rehabilitation aimed at functional restoration.

Many nursing homes have both unit types. Your parent might start on the skilled unit while in active rehabilitation, then transfer to the custodial unit if they need ongoing care but no longer need intensive skilled services.

The Three-Day Hospital Stay Requirement

Here's a detail that trips up many families: your parent needs to have been admitted to the hospital as an inpatient for at least three days before Medicare will cover skilled nursing facility care.

This doesn't mean three consecutive days in the hospital. It means three nights as an inpatient. If your parent goes to the hospital on a Monday and stays until Thursday, that's three nights. If your parent goes on a Monday and stays until Wednesday, that's two nights, which is not enough.

The hospital stay must be for the same condition you're being treated for in the skilled nursing facility. If your parent goes to the hospital for pneumonia, gets treated, and is discharged to a skilled nursing facility for pneumonia recovery, that works. If your parent goes to the hospital, is observed for a few hours, and is discharged to a facility, the observation stay might not count.

This is where observation status becomes critical and frustrating. Many people who go to the hospital are admitted as "observation status" rather than as inpatient admission. Observation status is typically for people expected to stay less than 24 hours and go home. But sometimes people in observation end up staying multiple days. Even if they're in the hospital for three days, the observation status doesn't count toward the three-day requirement.

You need to ask explicitly: "Is my parent an inpatient or observation?" The distinction matters enormously. If your parent is observation status, the days don't count toward the three-day requirement, and Medicare won't cover skilled nursing facility care even though your parent was in the hospital for three days.

This is one of the genuine gaps in Medicare where the system works against the patient. You can spend three nights in a hospital, be discharged to a facility, and discover that your days don't count because you were never technically an inpatient. Asking the hospital about admission status before discharge is one of the most important questions you can ask.

Coverage Timeline and Out-of-Pocket Costs

Medicare covers days one through 100 of skilled nursing facility care, but the cost structure changes partway through.

Days one through 20 are covered at 100 percent after your parent's Part A deductible is met. For 2024, that deductible is $1,632. Once it's paid, Medicare covers skilled nursing facility care with no copay or coinsurance for these first 20 days.

Days 21 through 100 require a daily copay. For 2024, that copay is $204 per day. Your parent or family is responsible for paying this amount for each day from day 21 to day 100. This is not a small amount. If your parent stays all 100 days, the copay for days 21 to 100 comes to $16,320.

Day 101 forward is not covered by Medicare at all. The entire cost becomes your parent's responsibility. If your parent is still in the skilled nursing facility on day 101, or any day after 100, Medicare is paying nothing. Every cost falls on your parent or family.

Some facilities accept Medicaid on day 101. If your parent qualifies for Medicaid (which depends on financial resources), Medicaid can cover skilled nursing facility care beyond day 100. But Medicaid has its own rules and approval process.

The Real-World Impact of 100-Day Limit

The 100-day limit is a hard ceiling, and it's often shorter than the recovery timeline for serious conditions.

A stroke survivor typically needs three to six months of rehabilitation to recover as much function as possible. Hip fracture recovery often takes longer. Serious illness recovery can take months. By day 100, your parent might be significantly better than at day three, but they might not be recovered enough to live independently.

Many patients hit day 95 and are still in active rehabilitation. They're still making progress. They're still improving. But the Medicare clock is running down. The conversation shifts from "How much will your parent improve?" to "What happens when Medicare stops paying?"

This creates real pressure on rehabilitation. Some families choose not to put their parent through intensive rehabilitation because the family can't afford private pay after day 100. Some families continue paying out of pocket. Some families discharge their parent to a less intensive setting. Some families move toward Medicaid planning or apply for long-term care insurance benefits.

The timing creates another problem: insurance and financial decisions have to happen mid-recovery, when the family is stressed and the outcome isn't clear.

Difference Between Skilled Care and Custodial Care Matters

This distinction determines payment and stays consistent throughout the facility placement.

Skilled care is medically necessary, requires professional judgment, and has a defined goal of restoration or improvement. Medicare covers this. Your parent's physical therapist is providing skilled care. Your parent's nurse assessing for complications is providing skilled care.

Custodial care is assistance with daily living that does not require a professional's judgment or a medical determination. Helping your parent dress, preparing meals, providing general supervision,these are custodial services. Medicare does not cover custodial care, even in a nursing facility.

Many patients need both. Your parent might need skilled nursing oversight, physical therapy, and help with bathing. The skilled services are covered by Medicare in a skilled facility setting. Once the skilled services end, the custodial services are not covered, and the facility stop being a Medicare-reimbursed placement.

This is why the transition planning conversation needs to happen before day 100. Your parent's care might change from skilled to custodial before day 100, which means coverage ends before day 100. Or your parent might still need skilled services at day 100, but those services run out of Medicare benefit, and coverage ends regardless of medical need.

Planning Ahead So the Transition Doesn't Surprise You

The 100-day limit is real and it's coming from the moment your parent enters. Planning for day 101 needs to start earlier than you'd think.

Ask your parent's doctor or therapist early about the expected length of stay. If your parent had a stroke, ask specifically, "Based on what you're seeing, when do you expect active rehabilitation to end? Will my parent be discharged or transferred?" Get an honest timeline, not an optimistic one. If your parent is three weeks in and the therapist says, "I expect another three months of active rehabilitation," you need to hear that.

If the expected length exceeds 100 days, start planning for payment immediately. Will your parent qualify for Medicaid on day 101? If yes, how do you apply? What are the asset limits and what do you need to spend down? If no, will your parent pay privately? Can the family afford this? Is long-term care insurance going to kick in?

Understand that Medicaid doesn't cover days 1 through 100 in a skilled facility. Medicaid covers custodial nursing home care, but there's a different process and a waiting period. If you're trying to transition your parent to Medicaid payment, there are specific rules about how assets are handled and what's considered a transfer. An elder law attorney can explain this.

Make sure the facility and your parent's doctor are communicating about the 100-day limit. Sometimes facilities transition patients to custodial status before day 100, which ends Medicare coverage earlier. Sometimes doctors think Medicare coverage continues longer than it does. Clarity on the actual end date matters for planning.

The Clock Is Always Running

Your parent doesn't have to actively be receiving services for the days to count toward the 100-day limit. If your parent is in the skilled facility but the physical therapist is off that day, the day still counts. The clock doesn't stop. Every day in the facility counts toward the 100-day limit.

This creates a subtle pressure toward continuing rehabilitation services even if your parent isn't making progress, just to justify continued skilled facility placement. Sometimes that pressure leads to continued therapy even when the benefit has plateaued. That's not necessarily the right decision medically, but it's the reality of the financial timeline.

Understanding the 100-day limit allows you to plan what actually happens on day 101. You know the benefit ends. You know what your parent will still need. You can make financial and care decisions with that information instead of discovering it when Medicare says, "We're no longer covering your bill starting tomorrow."

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's cognitive health or safety, consult with their healthcare provider or contact your local Area Agency on Aging for guidance and support.