The 100-Day Question: Medicare, Skilled Care, and Medicaid Long-Term Care
Ruth, 74, had a stroke and has been in a skilled nursing facility for 35 days following a 4-day inpatient hospital stay. She has Original Medicare with a stand-alone Part D plan. Her income is $1,450 per month in Social Security plus a $310 pension; her countable savings are $18,000. She is widowed and her daughter has durable power of attorney. The family's physician is not in the local Medicare Advantage network, and the family is asking whether Medicare will pay for Ruth to stay in the nursing home indefinitely. The facility's social worker is pushing the daughter to sign a private-pay admission agreement.
1. Explain what Medicare will and will not cover for Ruth's nursing facility stay, and where the coverage stops.
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Covered: A Medicare-covered SNF stay requires a qualifying inpatient hospital admission of at least 3 consecutive days (Ruth had 4) followed by admission to a SNF within 30 days, and a daily need for skilled nursing or skilled therapy. Medicare Part A covers up to 100 days per benefit period: days 1–20 at no coinsurance, days 21–100 with a daily coinsurance amount indexed annually (roughly $200+ per day in recent years).
Not covered: Custodial care - help with bathing, dressing, eating, supervision - is excluded when it is not accompanied by a skilled need. A stroke patient who plateaus in therapy loses the skilled justification even inside the 100 days, and the 100 days are a maximum, not an entitlement.
Why this matters here: Ruth's real long-term need is custodial. Medicare will not fund indefinite nursing home residence. The private-pay admission agreement is a legitimate risk for the daughter to sign without understanding that it obligates Ruth's (and potentially the daughter's) assets, depending on state law.
Action: the daughter should request the facility's therapy notes and the plan of care to determine whether a skilled need still exists at day 35, and ask for written notice before any Medicare-covered services stop, because a SNF termination triggers appeal rights.
2. Is Ruth likely eligible for Medicaid long-term care coverage? Analyze her income, resources, and the look-back, and identify the planning risks.
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Resources: $18,000 in countable savings is generally well under the state's resource limit for a single applicant (commonly around $2,000 countable for the individual, with the home excluded up to an equity limit if a spouse or certain relatives live there or if the applicant intends to return). She is widowed, so the community spouse resource allowance does not apply.
Income: $1,760/month total is above many states' medically needy income levels. In income-cap states this requires a Miller trust (Qualified Income Trust): her income goes into the trust, the state takes what it needs for her care up to the Medicaid rate, and the remainder is paid to her as a personal-needs allowance. In states using medically needy spend-down, she instead incurs medical bills until her income falls below the threshold.
Look-back: the state will review 5 years of transfers. Any gifts - including adding the daughter to a deed or bank account - create a penalty period of ineligibility. Nothing in the facts suggests a transfer, but the daughter must be asked directly before applying.
Estate recovery: the state will likely have a claim against the home at death.
Judgment: Ruth is resource-eligible and probably income-eligible via a Miller trust. The urgent step is to file the Medicaid application before the Medicare SNF coverage ends, because retroactive coverage windows are limited and gaps are billed privately.
3. The family asks whether Ruth should switch to a Medicare Advantage plan to save money, and whether she can buy a Medigap policy now. Advise them.
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Medicare Advantage: the appeal is lower premiums and extra benefits; the cost is network restriction and prior authorization. Ruth is mid-skilled-stay and the family physician is not in the local MA network. Switching mid-episode risks disrupting her therapy team and her physician relationship, and MA plans can require authorization for SNF continuation. For a patient with an active post-stroke rehab course, this is a bad time to change delivery systems. If she later stabilizes and cost is the driver, she can compare during the Annual Enrollment Period.
Medigap: Ruth is well past her 6-month Medigap open enrollment window, which ended six months after she first enrolled in Part B. Outside that window, in most states, carriers medically underwrite. A stroke history will make her a decline or a rated offer. Exceptions apply only in guaranteed-issue states, and limited federal guaranteed-issue rights (for example, losing certain retiree or MA coverage under specific circumstances) do not obviously apply here.
Practical answer: stay with Original Medicare for now, retain the Part D plan, and if she wants the cost protection later, explore whether her state has a guaranteed-issue window or a state-sponsored Medigap option. Do not let a Medigap purchase delay the Medicaid application, which is the coverage that actually funds her long-term care.