Medicare and Tricare coverage periods are not the same, and both have strict limits

Medicare pays for up to 100 days in a skilled nursing facility per benefit period, but only if you meet specific conditions: you must have been in a hospital for at least three consecutive days first, and you must be admitted to the nursing home within 30 days of hospital discharge. After 20 days, you pay a daily coinsurance amount (the exact dollar amount changes each year). After day 100, Medicare stops paying entirely.

Tricare (the military health program for active-duty families, retirees, and survivors) covers skilled nursing care differently. Tricare covers up to 60 days per benefit year in a skilled nursing facility, with no prior hospital stay required. After day 21, you pay a daily copay. Once you reach 60 days, Tricare stops covering that level of care for the rest of the year.

Neither program covers custodial care — help with bathing, dressing, meals, and daily activities when skilled nursing is not needed. If you need only custodial care, you pay out of pocket or through Medicaid (which has different rules and no day limits, though it requires a low income and assets test).

Key Takeaways

  • Medicare covers up to 100 days in a skilled nursing facility per benefit period, but only after a three-day hospital stay and only if admitted within 30 days of discharge.
  • Tricare covers up to 60 days per benefit year in a skilled nursing facility without requiring a prior hospital stay.
  • Both programs stop paying after their day limits are reached, even if you remain in the facility.
  • Neither Medicare nor Tricare covers custodial care, which is the most common type of long-term nursing home care.
  • If you exhaust Medicare or Tricare coverage, you must pay privately or transition to Medicaid if you meet income and asset limits.

How Medicare's 100-day limit works in practice

Medicare's skilled nursing benefit resets each benefit period (which runs October 1 to September 30). The clock starts only after you have spent three consecutive days in a hospital — not counting the day you are discharged. You must then be admitted to a Medicare-certified skilled nursing facility within 30 days of leaving the hospital.

Days 1 through 20 are fully covered by Medicare. Starting on day 21, you pay a coinsurance amount per day (in 2024, this is $200 per day, though the amount changes yearly). On day 101, Medicare coverage ends and you are responsible for all costs. If you are still in the facility, you must pay privately or switch to Medicaid if you meet the income and asset requirements.

The "benefit period" is not a calendar year. It ends 60 days after you have not received any inpatient hospital or skilled nursing care. Once a benefit period ends, a new one begins, and your 100-day count resets — but you must meet the three-day hospital stay requirement again to trigger the new benefit.

How Tricare's 60-day limit works in practice

Tricare's skilled nursing benefit year runs January 1 to December 31. Unlike Medicare, Tricare does not require a prior hospital stay. You can be admitted directly to a skilled nursing facility from home, a doctor's office, or an emergency room, and Tricare will cover it if the facility is in-network and the care is medically necessary.

Days 1 through 21 are fully covered. Starting on day 22, you pay a daily copay (the amount depends on your Tricare plan — Standard, Prime, or Select). On day 61, Tricare coverage stops for the remainder of that calendar year. You cannot use Tricare skilled nursing benefits again until January 1 of the following year.

If you are still in the facility after day 60, you must pay out of pocket or transition to another payer. Some Tricare beneficiaries are also may be able to access for Medicaid, which can continue coverage after Tricare stops, though Medicaid has its own rules and asset limits.

What happens when your coverage runs out

When Medicare or Tricare stops paying, the nursing home will ask you to sign a document acknowledging that you are now responsible for all costs. The facility cannot force you to leave, but you must arrange payment. The average cost of a semi-private room in a nursing home ranges widely by region — from under $6,000 per month in some areas to over $15,000 per month in others.

If you cannot pay privately, you have three main options. First, check whether you meet the income and asset limits for Medicaid, which covers nursing home care without a day limit (though it covers only the facility cost, not extras like phone or cable). Second, ask the nursing home about a payment plan or sliding scale based on income. Third, contact your state's long-term care ombudsman (a free advocate for nursing home residents) to discuss your options.

Some people also look into long-term care insurance, but this must be purchased before you need care, and premiums increase with age. If you already need nursing home care, long-term care insurance is not an option.

The difference between skilled nursing and custodial care

Medicare and Tricare only pay for skilled nursing care — care that requires a licensed nurse or therapist, such as wound care, intravenous medication, physical therapy, or monitoring after surgery. If you need only help with bathing, dressing, meals, toileting, and other daily activities (called custodial care), neither program will pay.

Most people in nursing homes need primarily custodial care, not skilled care. This is why Medicare and Tricare coverage often runs out quickly or does not explore at all. If you need only custodial care, you must pay out of pocket or use Medicaid (if you meet the income and asset test). Some assisted living facilities are less expensive than nursing homes and may be an option if you need custodial care but not skilled nursing.

Medicaid as a backup after Medicare or Tricare ends

Medicaid is a joint federal-state program that covers nursing home care without a day limit, but it requires you to have a low income and very limited assets. The asset limit varies by state but is typically $2,000 to $3,000 for an individual (not counting your home, one car, and some personal items). If you have more than this, you must spend down your savings before Medicaid will pay.

Medicaid also pays a lower daily rate than Medicare, so not all nursing homes accept Medicaid. Before your Medicare or Tricare coverage ends, ask the facility whether it accepts Medicaid and whether it will hold your bed while you complete the Medicaid process (which can take several weeks). Some states have "spend-down" programs that let you keep more assets if you put them into a trust or special account.

To start a Medicaid process, contact your state's Medicaid office or your county social services department. Bring proof of income, assets, citizenship, and residency. The process is free, but it is detailed and can take time.

Planning ahead: what to do before coverage runs out

If you are in a nursing home on Medicare or Tricare, start planning at least 30 days before your coverage ends. Ask the facility's social worker or business office for a written estimate of when your benefits will end and what your out-of-pocket cost will be. Request a meeting to discuss your options.

At the same time, contact your state Medicaid office to ask about the process process and whether you may be may be able to access. If you have family members who can help, involve them early — they may be able to help you gather documents or explore other funding sources. If you have a financial advisor or elder law attorney, this is the time to consult them about spend-down strategies or trusts.

Do not wait until the day your coverage ends. Nursing homes cannot discharge you solely because you cannot pay, but the facility can pursue collection action or place a lien on your home. Planning ahead gives you time to explore Medicaid, negotiate a payment plan, or make other arrangements.

Frequently Asked Questions

Can I get more than 100 days of Medicare coverage if I have a new hospital stay?

Yes. Each time you complete a benefit period (which ends 60 days after you leave the hospital or nursing home), a new benefit period begins. If you are readmitted to the hospital for at least three consecutive days and then admitted to a skilled nursing facility within 30 days, you get a new 100-day count. However, you must have a genuine new hospital stay — straightforward going to the emergency room and returning to the nursing home does not reset the clock.

Does Tricare cover nursing home care for family members of active-duty service members?

Tricare covers skilled nursing care for active-duty service members, retirees, and their family members (spouses and children under age 21, or up to age 23 if enrolled full-time in college). Coverage rules are the same for all beneficiaries: up to 60 days per calendar year with a daily copay after day 21. Family members must use an in-network facility.

What if I need nursing home care but do not meet the Medicare three-day hospital stay requirement?

Medicare will not pay. However, Tricare (if you are may be able to access) will cover skilled nursing without a prior hospital stay. If you have neither Tricare nor a prior hospital stay, you must pay privately or use Medicaid if you meet the income and asset limits. Some people also use long-term care insurance if they purchased a policy before needing care.

Can I appeal if Medicare or Tricare denies my claim or stops paying before I expected?

Yes. For Medicare, you have the right to request a detailed explanation and file an appeal. Contact Medicare at 1-800-MEDICARE or ask the nursing home's billing department for help. For Tricare, contact your regional Tricare office or call the Tricare customer service line. Both programs have formal appeal processes, though they can take several weeks.

If I run out of Medicare coverage, can I switch to Medicaid at the same nursing home?

Many nursing homes accept both Medicare and Medicaid, but not all. Before your Medicare coverage ends, ask the facility directly whether it accepts Medicaid and whether it will hold your bed while you complete the Medicaid process. Some facilities require you to move to a Medicaid-certified wing or room. Get this in writing before your coverage ends.