By Michael Shemtoub, trial attorney, Beverly Law. Updated November 2026.
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When Part A covers a skilled nursing facility
Medicare.gov lists the conditions for coverage:
- You have Part A and have days left in your benefit period.
- You had a medically necessary inpatient hospital stay of at least three days in a row. Time spent under observation or in the emergency room before admission does not count.
- You enter the facility within a short time, generally 30 days, after leaving the hospital.
- Your doctor or other provider has decided you need daily skilled care.
- The facility is Medicare-certified.
When those conditions are met, covered services include a semi-private room, meals, skilled nursing care, medications and physical, occupational and speech therapy if needed to meet a health goal. Medicare.gov notes that you may not need the three-day stay if your doctor takes part in an approved accountable care organization.
What a skilled nursing stay costs in 2026
| Days in the benefit period | What you pay in 2026 |
|---|---|
| Days 1 to 20 | $0 a day after the $1,736 Part A deductible |
| Days 21 to 100 | $217 a day |
| Day 101 and after | All costs |
The 2026 figures come from Medicare.gov and the CMS fact sheet released November 14, 2025, which shows the daily coinsurance for days 21 through 100 rising from $209.50 in 2025 to $217 in 2026 (CMS). Part A limits coverage to 100 days in each benefit period.
What Medicare does not pay
Long-term care, also called custodial care, is help with basic personal tasks of everyday life, sometimes called activities of daily living. Medicare does not cover custodial care if it is the only care you need, and Medicare.gov says that Medicare and most health insurance, including Medigap, do not pay for long-term care (Medicare.gov, long-term care). Medicare generally does not cover long-term nursing home stays unless you are receiving skilled nursing care. Part B can still pay for doctor visits and physical, speech and occupational therapy while you live in a nursing home (Medicare.gov, nursing home care).
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Medicare Advantage plans
A Medicare Advantage plan follows its own rules within Medicare’s. Medicare.gov says a plan may charge copayments during the first 20 days of a skilled nursing stay, and some plans waive the three-day hospital stay. For a long-term nursing home stay, plans usually do not help pay unless the nursing home has a contract with the plan (Medicare.gov). Call the plan before a transfer and ask which facilities are in its network.
Who pays for long-term care in California, Texas and Washington
Medicare.gov points people who need long-term care to Medicaid, if they meet their state’s eligibility rules, or to private long-term care insurance (Medicare.gov, long-term care). Each state runs its own program.
| State | Program | How nursing home care is paid |
|---|---|---|
| California | Medi-Cal | Since January 1, 2023, Medi-Cal managed care plans cover long-term care in skilled nursing facilities (DHCS). |
| Texas | Texas Medicaid | Since March 1, 2015, nursing facility services have been part of the STAR+PLUS managed care program (Texas HHSC). |
| Washington | Apple Health long-term services and supports | Apple Health pays for care at home or in a nursing facility for people who are eligible, and the resident may have to pay part of their income toward the cost, called client responsibility (DSHS 22-619). |
Medicaid that pays for long-term care can lead to a claim against the estate after death. Our page on whether a nursing home can take your house explains those rules state by state. Texas cases are handled by the firm’s Texas-licensed attorneys, Joyce Ondich and John Efstathiou.
Why Medicare matters in a neglect or abuse claim
A fall, a pressure injury or an infection at a nursing home can lead to hospital care, and Medicare may pay those bills. Federal law says Medicare should not pay when a liability insurance policy or plan, including a self-insured plan, can reasonably be expected to pay. When it pays anyway, the payment is conditional and must be repaid once a settlement or judgment comes in. The United States can sue to recover, and can collect double damages from an entity responsible for payment (42 U.S.C. 1395y(b)(2)).
CMS says a pending liability case must be reported to its Benefits Coordination & Recovery Center. The center sends a conditional payment letter within 65 days of its rights and responsibilities letter, then a final demand after the case resolves. Interest runs from the date of the demand letter, and the letter explains waiver and appeal rights (CMS recovery process). Our $50,000 settlement page walks through how fees and costs reduce Medicare’s share, and our medical liens page covers provider liens.
What this means for your case
Keep the hospital discharge papers that show whether the stay was inpatient or observation, because that controls skilled nursing coverage. Save every Medicare Summary Notice and plan statement from the dates of care. If you think the injury came from neglect, report the claim to Medicare early so the final numbers are ready when the case resolves. Our nursing home abuse section covers the facility records, and how long a nursing home lawsuit takes explains the steps and deadlines.
Common questions
Does Medicare pay if my mother was in the hospital under observation?
Observation time and time in the emergency room before admission do not count toward the three-day inpatient stay. Ask the hospital in writing how the stay was classified.
What happens after day 100?
You pay all costs for day 101 and after in that benefit period. Medicaid may pay for people who qualify.
Does Medigap pay for long-term nursing home care?
Medicare.gov says Medicare and most health insurance, including Medigap, do not pay for long-term care.
Will Medicare want money back from a nursing home neglect settlement?
If Medicare paid for care related to the injury, those conditional payments must be repaid from the settlement or judgment.
Does Medicare Advantage cover a skilled nursing stay?
Plans cover it under their own rules. A plan may charge copays during the first 20 days and may waive the three-day hospital stay. Beverly Law offers a free case review in English or Spanish at (310) 552-6959. You owe no fees or costs unless we win. Find more answers in our injury law FAQs.
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Related pages
Sources
- Medicare.gov, Skilled nursing facility care (medicare.gov)
- CMS, 2026 Medicare Parts A & B Premiums and Deductibles (Nov. 14, 2025) (cms.gov)
- Medicare.gov, Nursing home care (medicare.gov)
- Medicare.gov, Long-term care (medicare.gov)
- DHCS, CalAIM Skilled Nursing Facility Long-Term Care Carve-In (dhcs.ca.gov)
- Texas HHSC, STAR+PLUS Nursing Facility (pfd.hhs.texas.gov)
- Washington DSHS, Apple Health (Medicaid) and Long-Term Services and Supports for Adults (DSHS 22-619) (dshs.wa.gov)
- 42 U.S.C. 1395y(b)(2) (law.cornell.edu)
- CMS, Medicare's Recovery Process (cms.gov)
Important: This page is general information, not legal or medical advice, and reading it does not create an attorney-client relationship. Every case is different; talk to a lawyer about yours. Texas cases are handled by the firm’s Texas-licensed attorneys, Joyce Ondich and John Efstathiou. Last reviewed: November 7, 2026.