Medicare and Long-Term Care in Washington: What Medicare Pays, What It Doesn't, and Who Fills the Gap
Medicare will pay for up to 100 days in a skilled nursing facility after a hospital stay. It will not pay for the thing most families mean when they say "long-term care": someone to help Mom bathe, dress, get to the bathroom and take her pills, month after month. Medicare.gov says it in four words: "You pay all costs."
That gap matters because it is common. Federal researchers at HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE) estimate that 56% of Americans turning 65 will develop a disability serious enough to need long-term services and supports, and about 22% will have that disability for more than five years. Below is where Medicare's coverage stops, what it actually pays before that point, and the Washington programs that pick up (some of) the rest.
Source: ASPE, LTSS for Older Americans: Risks and Financing (2022); Medicare.gov, SNF care; CMS 2026 Part A and B fact sheet; WA Cares Fund, Benefits.
The line Medicare draws: skilled vs. custodial
Medicare is health insurance. It pays for care that needs a nurse, a therapist or a doctor, aimed at treating a condition or keeping it from getting worse. Long-term care is mostly something else. Medicare.gov describes it (also called "custodial care" or "long-term services and support") as help with the basic tasks of daily life: dressing, bathing, using the bathroom, plus things like home-delivered meals, adult day health care and transportation. Since most of that is non-medical, "Medicare and most health insurance, including Medicare Supplement Insurance (Medigap), don't pay for long-term care services, including care in a nursing home or in the community."
The setting doesn't change the answer. A nursing home bed can be covered skilled care on Tuesday and uncovered custodial care on Wednesday, in the same room, if what you need changes from daily therapy to help getting dressed.
| Type of care | What Medicare pays | What Medicare doesn't pay |
|---|---|---|
| Skilled nursing facility (SNF) | Up to 100 days per benefit period after a 3-day inpatient stay, if you need daily skilled care | Days 21 to 100 coinsurance ($217/day in 2026); everything after day 100; custodial-only stays |
| Home health | Part-time or intermittent skilled nursing and therapy if you're homebound; aide help as part of that care | 24-hour care, meal delivery, homemaker services, personal care when that's all you need |
| Hospice | Comfort care for a terminal illness (prognosis of 6 months or less), at home or in a facility | Room and board at home, in a nursing home or in a hospice facility (except short-term inpatient or respite stays the hospice arranges) |
| Help with daily activities at home | Nothing on its own | All of it |
| Assisted living or adult family home | Nothing for the residence or personal care | All of it (Medicare still covers your medical care) |
| Long-term nursing home stay | Nothing for custodial care | All of it |
Source: Medicare.gov, Long-term care; SNF care; Home health services; Hospice care; Medicare & You 2027.
The 100 SNF days, in 2026 dollars
The SNF benefit is the one people mistake for long-term care coverage, so it's worth being exact. Part A covers skilled nursing facility care only if you meet every condition: a medically necessary inpatient hospital stay of at least 3 days in a row (the day you're admitted counts, the day you leave doesn't, and observation or ER time doesn't count at all), admission to a Medicare-certified SNF generally within 30 days of leaving the hospital, and a doctor's order for daily skilled care related to that stay. (42 CFR 409.30).
Then the clock runs. For each benefit period in 2026, per Medicare.gov:
- Days 1 to 20: no daily charge (the $1,736 Part A deductible applies, but you normally paid it already for the hospital stay in the same benefit period).
- Days 21 to 100: $217 a day.
- Day 101 on: you pay all costs.
CMS hasn't announced the 2027 Part A deductible or SNF coinsurance as of November 6, 2026. CMS announced the 2026 figures on November 14, 2025. When the 2027 numbers come out, the structure stays the same: only the dollar amounts change.
Source: CMS 2026 Part A and B fact sheet; Medicare.gov, SNF care. Calculation by Maru Insurance.
Show the numbers
| Days in the SNF | You pay |
|---|---|
| 20 days | $0 |
| 30 days | $2,170 |
| 45 days | $5,425 |
| 60 days | $8,680 |
| 100 days | $17,360 |
Two things the chart can't show. First, most SNF stays end long before day 100, and not because the days run out. Coverage stops when you no longer need daily skilled care. If what's left is help with bathing and dressing, the handbook is plain: Medicare doesn't cover non-medical, long-term care. Second, the handbook says you may get skilled nursing care or therapy when it's needed to improve or maintain your condition, and if you're discharged only because you aren't improving but still need skilled care to keep your condition from getting worse, you can appeal. I cover the appeal steps in Medicare skilled nursing facility coverage.
The 100 days renew with each new benefit period, which starts after 60 days in a row without inpatient hospital or SNF care (42 CFR 409.60). That helps with a second hospitalization months later. It does nothing for someone who needs help every day for three years.
Home health and hospice: real benefits, narrow ones
Home health. If you're homebound and need part-time or intermittent skilled care (nursing, physical or occupational therapy, speech therapy), Part A or Part B covers it and you pay nothing for the services themselves. Medicare.gov says "part-time or intermittent" usually means skilled nursing and home health aide services combined up to 8 hours a day and no more than 28 hours a week, with short stretches of up to 35 hours a week when your provider says it's necessary. Durable medical equipment is 20% after the Part B deductible.
The exclusions are the long-term care list: 24-hour care at home, home meal delivery, homemaker services like shopping and cleaning unrelated to your care plan, and "custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need." Once the skilled need ends, the aide visits end with it.
Hospice. For someone with a terminal illness and a life expectancy of 6 months or less who chooses comfort care, Part A hospice is broad: you pay nothing for covered hospice care from a Medicare-approved provider, up to $5 per prescription for pain and symptom drugs, and possibly 5% of the Medicare-approved amount for inpatient respite care, which gives a family caregiver a break of up to 5 days at a time (Medicare.gov, Hospice care). The gap again is custodial: Medicare doesn't cover room and board whether hospice happens at home, in a nursing home or in a hospice inpatient facility, unless it's a short-term inpatient or respite stay the hospice team arranges. A parent in memory care who enters hospice still owes the facility's monthly bill.
How the gap shows up (example)
WA Cares Fund: Washington's new layer
Since July 1, 2026, Washington has paid benefits from the WA Cares Fund, which the state calls the first public long-term care insurance program in the country. It pays for exactly the custodial and support services Medicare excludes. Workers fund it through a payroll premium of 0.58% of gross wages; employers pay no share (WA Cares, Employers).
Source: WA Cares Fund, Benefits; Qualify; Employers.
Who qualifies. Two tests. The care test: a WA Cares team member must find that you need help with at least three of seven activities (bathing, bed mobility, eating, medication management, mobility, transferring, toileting) and will keep needing it for at least 90 days; needing supervision or cueing counts. The contribution test has three paths, and each calendar year counts if you worked at least 500 hours in it (WA Cares, Qualify):
| Pathway | Requirement | Benefit |
|---|---|---|
| Permanent | Contributed at least 10 years | Full benefit ($36,500 in 2026) |
| Temporary | Contributed at least 3 of the past 6 years when you apply | Full benefit ($36,500 in 2026) |
| Transition | Born before January 1, 1968, and contributed at least 1 year | 10% of the full benefit per year contributed (currently $3,650 a year) |
Source: WA Cares Fund, Qualify.
What it pays for. In-home personal care (including a family member as paid caregiver), home-delivered meals, housework and errands, home modifications, emergency response systems, adult day services, transportation, respite for family caregivers, assisted living, adult family homes, memory care and nursing homes. WA Cares pays the provider directly; some services aren't available statewide (WA Cares, Benefits).
How far it goes. WA Cares itself says the benefit could cover around 20 hours a week of home care for about a year (FAQ). For a facility, here's a rough yardstick: Washington's Health Care Authority lists a statewide average private nursing facility rate of $485 a day ($14,759 a month) as of October 1, 2026. That's the figure the state uses when it calculates Medicaid transfer penalties (WAC 182-513-1363). At that rate, $36,500 covers about 75 days. Actual prices vary by facility and region; this is arithmetic, not a quote.
The catch for current retirees. If you're retired and don't work at all, you can't earn WA Cares benefits. Retirees who still work at least 500 hours a year contribute and can earn them. So many people already on Medicare won't have it, while workers paying the premium in Seattle, Spokane or Vancouver today are building it.
Two features make it fit well with Apple Health: WA Cares benefits don't count as income or resources for Medicaid eligibility (RCW 50B.04.150), and the program says they aren't subject to estate recovery. The eligibility details, exemptions and the out-of-state option (benefits for people who moved away start in July 2030) are in my full WA Cares Fund explainer.
Apple Health long-term services and supports
For most Washingtonians who need years of care, Apple Health (Washington's Medicaid) is the payer that eventually steps in. Medicare.gov puts it plainly: Medicaid offers benefits not normally covered by Medicare, "like nursing home care and personal care services" (Medicare.gov, Medicaid). If you have both, Medicare still pays first for medical care.
Apple Health long-term services and supports (LTSS) can pay for care at home, in an assisted living facility or adult family home, or in a nursing facility. You must pass both a financial test and a functional one, a CARE assessment by a DSHS social services worker. Your Area Agency on Aging or local Home and Community Services office is a good place to start. Services start once you meet nursing facility level of care and a caregiver is in place (HCA, Long-term care and hospice).
| Rule | Washington figure or standard |
|---|---|
| Countable resource limit, single person | $2,000 (WAC 182-513-1350) |
| Countable resource limit, married couple (both applying) | $3,000, with separate rules when one spouse stays at home |
| Home equity limit (1/1/26) | $1,130,000 |
| Federal spousal resource maximum (1/1/26) | $162,660 |
| Look-back for asset transfers | 60 months before applying |
| Usually exempt | Primary home, household goods, a car, life insurance with face value up to $1,500, burial plots, most prepaid burial plans |
| Daily private nursing facility rate used for penalties (10/1/26) | $485 |
Source: WAC 182-513-1350; HCA Apple Health Income and Resource Standards, Oct 1, 2026; DSHS 22-619 (Rev. 1/26); WAC 182-513-1363.
Income limits differ by program, living situation and marital status, and DSHS says the local HCS office has current figures. A few things families often miss:
- Estate recovery. For people 55 and older, Washington can recover what it paid for nursing facility care, home and community-based services and related hospital and drug costs from the estate (RCW 43.20B.080). It applies only to some LTSS programs, not all Apple Health.
- Help for unpaid caregivers. Tailored Supports for Older Adults (TSOA) and Medicaid Alternative Care (MAC) support a family caregiver with respite, supplies and training. The care receiver must be 55 or older. TSOA has its own, much higher resource standard and isn't medical coverage; per HCA's fact sheet, estate recovery doesn't apply to MAC or TSOA.
- How to apply. Washington Connection online, paper Form 18-005, or an HCS office. More on how the two programs coordinate: Apple Health and Medicare.
Private long-term care insurance, as OIC regulates it
The third option is a private policy. No companies or prices here; the point is to know what the Washington Office of the Insurance Commissioner (OIC) treats as long-term care insurance, so you can read a policy you own or ask good questions about one.
What counts. Per OIC, long-term care insurance is coverage that lasts at least 12 months in a row for a serious, long-lasting illness or disability, and it usually starts paying when you can't do two or more activities of daily living on your own. It can be attached to a life insurance or annuity policy, but an accelerated death benefit or critical illness rider that just converts a life policy to cash doesn't qualify in Washington.
Premium increases. OIC says early long-term care policies were underpriced, and insurers must get its approval for rate increases; when an increase is justified and lawful, OIC can't deny it. If an increase arrives, the OIC page lists the usual options: lower the daily benefit, shorten the benefit period, lengthen the elimination (waiting) period, reduce inflation protection, or take a contingent non-forfeiture option that stops premiums and keeps a reduced benefit.
The Partnership program. A policy certified under Washington's Long-Term Care Partnership Program gives dollar-for-dollar Medicaid asset protection: OIC's example is that if the policy pays $200,000, Medicaid lets you keep $200,000 in assets on top of the normal limit. A Partnership policy says so on the policy or rider and comes with a separate Partnership disclosure notice.
Supplemental policies that sit on top of WA Cares. Washington now allows supplemental policies that start paying after your WA Cares benefit is used up. As of today, OIC says insurers are not yet selling them; companies still need to develop and file them. When they arrive, they must provide at least 12 months of coverage, and standalone supplemental policies must include inflation protection.
The Washington options side by side
| Source | Who qualifies | What it pays for | Where to start |
|---|---|---|---|
| Medicare (Part A/B) | Medicare enrollees meeting the SNF, home health or hospice rules | Short-term skilled care; no custodial care | Medicare.gov, 1-800-MEDICARE, SHIBA |
| WA Cares Fund | Workers who contributed (10 years, 3 of last 6, or born before 1968 for partial) and need help with 3+ of 7 activities for 90+ days | Home care, family caregiver pay, meals, home changes, facilities; up to $36,500 lifetime (2026) | WA Cares benefits account; 844-CARE4WA |
| Apple Health LTSS | Low income and resources ($2,000 for a single person) plus nursing facility level of care | Home care, assisted living, adult family home, nursing facility | Washington Connection; DSHS HCS; Area Agency on Aging |
| Private LTC insurance | Whoever bought a policy and meets its benefit triggers (usually 2+ daily activities) | What the policy says: daily or monthly benefit, for its benefit period | Your policy; OIC Consumer Advocacy 800-562-6900 |
Source: Medicare.gov, Long-term care; WA Cares Fund, Qualify; HCA, Long-term care and hospice; WAC 182-513-1350; OIC, Long-term care.
In real life these stack: Medicare pays for the hospital and the first weeks of rehab, WA Cares (if you have it) for months of home help, a private policy for what it covers, and Apple Health is the floor once savings reach the limit. Knowing the order lets a family plan instead of reacting on day 31.
Do Medigap or Medicare Advantage fill the gap?
Not for custodial care. Medicare.gov's long-term care page names Medigap specifically as coverage that doesn't pay for long-term care. Medigap fills Original Medicare's cost-sharing, so it follows Medicare's definition of covered care; see our page on Medicare Supplement insurance in Washington.
Medicare Advantage plans must cover everything Original Medicare covers, so they cover SNF, home health and hospice under the same basic idea, though Medicare.gov notes a plan may charge copays during the first 20 SNF days, and plans can require prior authorization. Hospice is still paid by Original Medicare even if you're in a Medicare Advantage plan (MedPAC, March 2026). None of that is a long-term care funding plan. SHIBA's counselors will walk through your Medicare options without selling anything; here's how SHIBA works.
What to do now
- If someone is in a SNF now, ask the facility every week whether Medicare is still covering the stay, and ask for the written notice if coverage is ending. You should get a Notice of Medicare Non-Coverage at least 2 days before covered services end, and a fast appeal has to be requested by the deadline printed on it (Medicare.gov, Fast appeals).
- If you're still working, create a WA Cares benefits account through SecureAccess Washington and check your contribution history. If you were born before 1968, every year of contributions adds $3,650 (2026 figure) to what you can use.
- If you have an older private policy, find it and note the benefit trigger, daily or monthly benefit, benefit period, elimination period, and whether it's a Partnership policy. Tell your family where it is.
- If savings are limited, call your Area Agency on Aging (855-567-0252) or DSHS Home and Community Services before you move anyone into a facility, so you understand Apple Health LTSS and the 60-month look-back first. For a will, trust or asset-transfer question, that's an elder law attorney's job.
- For Medicare questions, SHIBA (800-562-6900) gives free, unbiased help. For long-term care insurance questions, OIC's Consumer Advocacy line is the same number.
For a broader look at how Medicare works here, see our page on Medicare coverage in Washington.
Questions
Does Medicare pay for long-term care in Washington?
No. Medicare doesn't pay for long-term custodial care, such as help with bathing, dressing or using the bathroom, at home, in assisted living or in a nursing home. It covers short-term skilled care: up to 100 days in a skilled nursing facility after a 3-day inpatient stay, part-time home health care if you're homebound, and hospice.
How much does Medicare pay for a nursing home in 2026?
For a qualifying skilled nursing facility stay, Original Medicare pays in full for days 1 to 20, you pay $217 a day for days 21 to 100, and you pay all costs after day 100. CMS had not announced the 2027 amounts as of November 6, 2026. A custodial nursing home stay isn't covered at all.
Can I use WA Cares if I'm already on Medicare?
Only if you contributed. WA Cares premiums began July 1, 2023. If you're retired and don't work at all, you can't earn benefits; retirees who still work at least 500 hours a year contribute and can earn them. If you were born before 1968 and worked at least 500 hours in a year after that, you earn $3,650 per year contributed (2026 figure), and you also have to need help with 3 of 7 daily activities for at least 90 days.
Who pays for long-term care in Washington if I can't afford it?
Apple Health (Medicaid) long-term services and supports can pay for care at home, in assisted living or adult family homes, or in a nursing facility if you meet the financial rules (a $2,000 resource limit for a single person) and a functional assessment. Start with DSHS Home and Community Services or your Area Agency on Aging.
Your own policy wording and Washington law control. Program rules and dollar figures change, often each January. Confirm your situation with a licensed agent, SHIBA, the Washington Office of the Insurance Commissioner, DSHS, or (for estate and asset questions) an attorney.
Sources
- Medicare.gov: Long-term care
- CMS: Medicare & You 2027 handbook
- Medicare.gov: Skilled nursing facility (SNF) care
- CMS: 2026 Medicare Parts A and B premiums and deductibles fact sheet (Nov 14, 2025)
- eCFR: 42 CFR 409.30, requirements for posthospital SNF care
- eCFR: 42 CFR 409.60, benefit periods
- Medicare.gov: Home health services
- Medicare.gov: Hospice care
- ASPE (HHS): Long-Term Services and Supports for Older Americans: Risks and Financing, 2022
- WA Cares Fund: Benefits now available (July 1, 2026)
- WA Cares Fund: Benefits
- WA Cares Fund: Qualify
- WA Cares Fund: Employers (premium rate)
- WA Cares Fund: Frequently asked questions
- RCW 50B.04.150: benefits not income or resources
- Washington HCA: Long-term care and hospice
- Washington HCA: Apple Health Income and Resource Standards, October 1, 2026
- Washington HCA: Apple Health Long-Term Services and Supports fact sheet (HCA 19-0009)
- DSHS: Apple Health (Medicaid) and Long-Term Services and Supports for Adults (22-619, Rev. 1/26)
- WAC 182-513-1350: LTC resource standards
- WAC 182-513-1363: asset transfers and penalty periods
- RCW 43.20B.080: Medicaid estate recovery
- Medicare.gov: Medicaid
- Washington OIC: Long-term care
- Washington OIC: What qualifies as long-term care insurance
- Washington OIC: Long-term care insurance rate increases
- Washington OIC: Long-Term Care Partnership Program
- Washington OIC: Supplemental long-term care insurance
- Washington OIC: SHIBA free Medicare help
- Medicare.gov: Fast appeals
- MedPAC: March 2026 Report to the Congress, hospice chapter
This article is for general educational purposes only and is not legal, tax or insurance advice. Coverage depends on the actual policy, its terms, conditions and exclusions, and state law. Maru Insurance · WA License (WAOIC) #1365574 · FL License #G363233 · NPN 22261820.