Who Pays For A Skilled Nursing Stay…Medicare Or You?

UNITED STATES—Dear Toni, My husband, Steve, is having a situation after emergency surgery in January from a fall.  He was in a skilled nursing facility for over 2 months, re-learning how to walk.  Since he has Medicare only, he was billed over $1,700 because he did not have a Medicare Supplement or Medicare Advantage plan to pay what Original Medicare does not pay. The skilled nursing facility also charged him over $8,000, and he’s paying this out of his own pocket. He did enroll into a Medicare Part D plan with a $0 monthly premium.

Here’s his problem. Steve returned to the hospital in July for additional surgery and had another round of skilled nursing.  There’s another out-of-pocket charge of $1,700 for the July incident because Medicare says that’s another skilled nursing benefit period. A Medicare representative advised him to enroll in a Medicare Advantage Plan during Medicare’s Open Enrollment Period beginning Oct. 15. The plan would begin Jan. 1.

Steve is confused about what he should do and how to find the right Medicare Advantage plan. Please explain what his options are.  Thanks, Toni. Mary from Arlington, Texas

Hello Mary: On pages 27-29 of the 2026 Medicare & You handbook, it sets out what Medicare Part A covers and what it doesn’t, explaining both “Inpatient Hospital Care and Skilled Nursing” benefits. For 2026, the Part A inpatient hospital deductible is $1,736, which is not a once-a year- deductible, but occurs six times a year. This means that the Part A deductible starts over every 60 days. (Steve’s $1,700 out-of-pocket, actually was $1,736 per inpatient hospital stay in January and July.)

The 2026 Part A costs for a skilled nursing stay are a $0 copay per day for days 1-20 and $217 per day for days 21-100. After day 100, Steve is responsible for 100% of his remaining stay since he does not have a Medicare Supplement or Medicare Advantage (MA) plan to pick up the out-of-pocket cost. Mary, I am sure that he understands why he should have chosen either a supplement or an MA plan.

The 2026 Part B medical/doctor deductible of $283 began Jan. 1, 2026. After the deductible is met, Medicare pays 80% of the Medicare-approved amount and the Medicare beneficiary pays the remaining 20% of the Medicare-approved amount. Steve could have some out of pocket with Part B due to his medical issues.

Since he is searching for the right MA plan to enroll in during Medicare’s Open Enrollment Period which starts Thursday, Oct. 15, I would advise him to consult his current skilled nursing facility, medical providers, medical facilities and hospital to find out if they accept a Medicare Advantage plan network, whether an HMO or a PPO plan.  Once he’s enrolled in an MA plan, the new policy will start Friday, Jan. 1, 2027.

Due to Steve’s medical issues, he might not be able to pass the medical underwriting questions required for him to qualify for a Medicare Supplement plan. That is why I am suggesting that he enroll in a Medicare Advantage plan either HMO or PPO during the coming Medicare OEP.

That brings me to the good news I have for Steve!  Because he is already enrolled in a stand-alone Medicare Part D plan, he can enroll into a Medicare Advantage Part D (MAPD) plan during Medicare’s Open Enrollment Period without having any problems.  His Part D plan will change to the MAPD plan he has chosen.  He can call 1-800-Medicare (633-4227), go to www.medicare.gov and enroll online or call the chosen MAPD insurance plan directly to enroll.

Remember, with Medicare, what you don’t know WILL hurt you!

Mary, if you or Steve have any questions about his Medicare situation, you can call the Toni Says Medicare team at 832-519-8664 or email info@tonisays.com for advice on plans. Toni’s “Medicare First Steps,” available at www.tonisays.com details various situations during Medicare’s Open Enrollment Period.

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Toni King is an author and columnist on Medicare, Social Security, and long-term care issues. She has spent nearly 20 years as a top sales leader in the field. If you have a Medicare question or concern, email info@tonisays.com or call 832-519-8664.