What Medicare Doesn’t Pay For:
What Nurse Case Managers Should Know—and How to Explain It to Patients and Families
As nurse case managers, we often become the frontline educators when it comes to navigating Medicare coverage. And one of the hardest parts of our role is explaining what isn’t covered—especially when families are stressed, overwhelmed, or making decisions quickly.
Below is a breakdown of key Medicare coverage gaps, what case managers should understand clinically, and how to communicate those realities clearly and compassionately.
1. Custodial (Non-Skilled) Care — Including Long-Term SNF Stays
What You Should Know:
Medicare covers skilled care (e.g., wound care, IV therapy, rehab) for a limited time. It does not pay for help with daily activities like bathing, toileting, or dressing. Once the skilled need ends, room and board costs become private pay.
💬How to Explain It to Families:
“Medicare pays for short-term care when there’s a skilled need—like wound treatment or physical therapy. But once that ends, Medicare no longer covers the stay, even if your loved one still needs help with daily care. That’s when it becomes private pay or a Medi-Cal discussion.”
2. Skilled Nursing Facility Without a Qualifying Inpatient Stay
What You Should Know:
Medicare requires a three-midnight inpatient stay (not observation) to approve SNF coverage. Observation stays, even in a hospital bed, do not qualify.
💬How to Explain It to Families:
“Medicare has strict rules. Unless a patient is admitted for three full nights, they won’t qualify for skilled nursing coverage—even if it seems like the same level of hospital care. It’s not something we can override; it’s a federal policy.”
3. Assisted Living or Board & Care (ALF/RCFE)
What You Should Know:
Assisted Living Facilities (ALFs) and Residential Care Facilities for the Elderly (RCFEs) are non-medical. Medicare does not pay for meals, housing, or personal care services offered in these settings.
💬How to Explain It to Families:
“Facilities like assisted living or board-and-care homes provide meals and help with daily activities—but since there’s no skilled medical care, Medicare doesn’t cover them. These are private-pay options, though we can talk about Medi-Cal programs if you qualify.”
4. 24-Hour or Live-In Care at Home
What You Should Know:
Medicare home health only covers intermittent visits for skilled needs. It does not pay for caregivers who stay overnight, assist with meals, or provide ongoing supervision.
💬How to Explain It to Families:
“Medicare pays for short, skilled home visits—like a nurse coming by a few times a week. It doesn’t cover live-in help or full-time caregivers. If your loved one needs around-the-clock support, we’ll need to talk about private caregivers or community resources.”
Final Thoughts for Case Managers:
Set boundaries early in the care plan process. It’s not our job to “make it happen” if it’s not covered—we educate and guide.
Use clear language and avoid medical jargon. Most families have never heard of a “qualifying stay” or understand the difference between observation and admission.
Offer realistic options, not false hope. Connecting patients to Medi-Cal, Area Agencies on Aging, or long-term care ombudsman programs is more helpful than vague promises.
Protect your own emotional bandwidth. These rules come from Medicare, not you. Don't carry guilt for policies you didn’t create.
💬 Suggested Script to Keep Handy:
“I know this is overwhelming. Medicare has very specific rules about what they cover, and it can feel frustrating. My job is to help you understand what’s covered, what’s not, and what your options are—so you can make the best decision possible for your family.”
