Medicare does not pay for nursing homes in Texas in the way most families expect. It covers short-term skilled nursing care after a qualifying hospital stay — up to 100 days per benefit period — and pays nothing for long-term custodial care, which is what the vast majority of nursing home residents actually need. Once the skilled need ends or the 100 days run out, the bill shifts to you, your family, or Texas Medicaid.
Skilled Care vs. Custodial Care
Medicare draws a hard line between two kinds of care. Skilled care requires licensed professionals — registered nurses, physical therapists, speech-language pathologists — treating a specific medical condition. Custodial care is help with daily activities: bathing, dressing, eating, moving in and out of bed. Most nursing home care is custodial, and Medicare does not pay for any of it.1Medicare.gov. Nursing Home Coverage – Medicare
One point worth clearing up: Medicare does not require that you be improving. After the settlement in Jimmo v. Sebelius, CMS confirmed that skilled care to maintain your condition or slow a decline is covered, even when full recovery is not expected. What matters is whether the care itself needs a trained professional.2Centers for Medicare & Medicaid Services. Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet
How You Qualify for the 100 Days
Several conditions have to line up at the same time. Miss one and Medicare denies the entire stay.
Three Consecutive Days as a Hospital Inpatient
You need at least three consecutive days admitted to a hospital as a formal inpatient before transferring to a skilled nursing facility. The clock starts the day you are admitted and does not include the day you are discharged.3Medicare.gov. Skilled Nursing Facility Care
Here is where many Texas families get caught. Time spent in “observation status” does not count, even if you slept in a hospital bed for several nights, because Medicare treats observation as outpatient care. Hospitals are required to give you a written Medicare Outpatient Observation Notice when this applies. If you receive one, ask the doctor whether a formal inpatient admission is appropriate — the answer can decide whether Medicare pays for any nursing facility stay that follows.4Centers for Medicare & Medicaid Services. Medicare Outpatient Observation Notice (MOON)
Physician Certification and a Certified Facility
A doctor has to certify that you need daily skilled nursing or skilled therapy that can only be provided in a facility, and that the care relates to the condition treated during the qualifying hospital stay. The facility itself has to hold active Medicare certification. Not every Texas nursing home does, so confirm this before transferring.5eCFR. 42 CFR Part 424 Subpart B – Certification and Plan Requirements
If You Have Medicare Advantage
Medicare Advantage plans (Part C) have to cover at least the same skilled nursing benefits as Original Medicare, but many waive the three-day inpatient hospital requirement. The trade-off is that your plan may restrict you to in-network facilities. Call your plan before any transfer to confirm its rules.3Medicare.gov. Skilled Nursing Facility Care
What a Covered Stay Actually Costs in 2026
Even during the covered 100 days, Medicare does not pick up every dollar. Your share depends on where you are inside a single benefit period:
- Days 1 through 20: $0 per day in coinsurance. The $1,736 Part A deductible applies once per benefit period and was typically paid during the hospital stay.
- Days 21 through 100: $217 per day in coinsurance.
- Day 101 and beyond: you pay everything. Medicare coverage ends.
A stay that runs the full 100 days produces $17,360 in coinsurance alone for days 21 through 100. A Medigap policy may absorb part or all of that, depending on which plan you hold. CMS adjusts these numbers each year.6Centers for Medicare & Medicaid Services. Medicare Deductible, Coinsurance and Premium Rates CY 2026 Update
Coverage can also stop before you hit day 100. If the care team decides your condition no longer needs daily skilled intervention, Medicare’s share ends at that point.
Benefit Periods and When the Clock Resets
The 100-day limit is per benefit period, not per calendar year. A benefit period begins the day you are admitted as an inpatient to a hospital or skilled nursing facility and ends after you have gone 60 consecutive days with no inpatient hospital or skilled nursing care.7eCFR. 42 CFR Part 409 Subpart F – Scope of Hospital Insurance Benefits A new admission after that gap starts a fresh benefit period and a fresh 100 days — along with a new Part A deductible and, under Original Medicare, a new three-day qualifying hospital stay.
If the Facility Says Medicare Is Cutting You Off
A skilled nursing facility cannot quietly stop billing Medicare. Before coverage ends, it has to give you a written Notice of Medicare Non-Coverage at least two days ahead of the end date, with the reason.8Centers for Medicare & Medicaid Services. Form Instructions for the Notice of Medicare Non-Coverage (NOMNC)
If you disagree, request a fast appeal with the Beneficiary and Family Centered Care–Quality Improvement Organization. File by noon the day before the termination date on the notice. Medicare keeps paying while the review is underway. The organization reviews the records, asks why you believe coverage should continue, and decides by the close of business the day after it has what it needs. Win the appeal, and coverage continues. Lose it, and you still owe nothing for care provided before the original end date.9Medicare.gov. Fast Appeals
What Pays for Long-Term Nursing Home Care in Texas
Once Medicare is done, Texas families typically rely on private funds or Texas Medicaid. The Texas Health and Human Services Commission runs STAR+PLUS, a managed-care program that combines medical services with long-term support for adults 65 and older or those with disabilities.10Texas Health and Human Services. STAR+PLUS
Income and Asset Limits
Texas uses an income ceiling of 300 percent of the federal SSI benefit rate. With the 2026 SSI rate at $994 per month, the ceiling for an individual is $2,982 per month.11Social Security Administration. SSI Federal Payment Amounts Countable assets have to stay at or below $2,000 for an individual. A primary home (within equity limits), one vehicle, personal belongings, and a prepaid burial plan are exempt. You also have to pass a medical necessity evaluation confirming that you need nursing-facility-level care.12Texas Health and Human Services. F-1300, Resource Limits
Protections for a Spouse Who Stays Home
Federal spousal impoverishment rules keep Medicaid from draining a married couple’s savings. The spouse who remains at home can keep a portion of the couple’s combined assets through the Community Spouse Resource Allowance, which in 2026 ranges from a federal minimum of $32,532 to a maximum of $162,660 depending on the couple’s resources. The at-home spouse is also entitled to a minimum monthly income allowance for basic living costs. A married couple does not have to spend down to zero before one spouse can qualify.
What Private Pay Looks Like in Texas
The gap matters because private rates are high. As of early 2026, a semi-private nursing home room in Texas runs about $5,800 per month at the median, roughly $190 per day. Private rooms and specialized memory care cost more. At the median rate, a year of care tops $69,000, which is why planning for the period after Medicare’s 100 days closes is the real question for most Texas families, not whether Medicare will cover the stay itself.