Your mom has been in rehab after a hospital stay. Now the social worker says Medicare coverage ends in two days because she "isn't making progress" or has "plateaued." She still can't stand up without help, and you have no idea how she would manage at home.
Two things are worth knowing right away. First, "she isn't improving" is not, by itself, a reason for Medicare to stop paying for skilled nursing care. Medicare looks at whether she still needs skilled care, and that can include care to keep her from getting worse. Second, Medicare was never going to pay for a long nursing home stay. Up to 100 days per benefit period is the most it covers, and only while she needs daily skilled care. So it helps to push back where the rules are on your side and to start planning for what comes next, both at the same time.
This isn't legal or medical advice. Ask the nurse and the therapists what they see, and talk to an elder law attorney about money and Medicaid questions.
Can Medicare stop because she isn't improving?
Medicare can't end coverage for that reason alone. In 2013, a court approved a settlement in a case called Jimmo v. Sebelius. CMS, the agency that runs Medicare, says on its Jimmo page that coverage in a skilled nursing facility "does not turn on the presence or absence of a beneficiary's potential for improvement," and depends instead "on the beneficiary's need for skilled care."
Medicare.gov says the same thing in plain words. Medicare can cover skilled nursing care or therapy in a skilled nursing facility when you need it "to improve or maintain your current condition, or to prevent or delay it from getting worse."
The settlement did not change the other rules. CMS's Jimmo questions and answers say the 100-day limit still applies, and care that an aide or the family could give safely, without a nurse or therapist's skill, is not covered. So the real question for your mom's team is whether she still needs care that only a nurse or therapist can safely give, every day.
What to say to the team
Ask for a care plan meeting, and bring a notebook. These are fair questions:
"I've been told her coverage is ending because she isn't improving. Is that the reason? Does she still need skilled nursing or therapy to keep her from getting worse?"
"Can I see the therapy notes and her current goals? If she has stopped improving, has anyone written maintenance goals?"
"What exactly can she do on her own right now, and what does she need help with?"
CMS's questions and answers say that when a patient stops improving, the provider has to decide whether skilled care is needed to maintain her condition, and if so, write new maintenance goals into her plan of care. If the only explanation you hear is "she's plateaued," ask about this.
If you disagree, appeal before the deadline
When Medicare coverage in rehab is ending, your mom should get a written Notice of Medicare Non-Coverage at least two days before her covered care ends. It explains how to ask for a fast appeal from an independent reviewer. The deadline is noon the day before coverage ends, so call the number on the notice right away. Our guide to unsafe discharge and the Medicare fast appeal walks through every step and the words to use.
If she has a Medicare Advantage plan, the plan may have its own approval rules and copays. Follow the notice and call the plan.
The 100-day myth
Many families hear "Medicare covers 100 days" and plan around it. Medicare covers up to 100 days in a skilled nursing facility for each benefit period, and only while all the rules are met. Coverage can end long before day 100 if the team decides she no longer needs daily skilled care.
To qualify in the first place, Medicare.gov lists a medically necessary inpatient hospital stay of at least three days in a row (time under observation or in the emergency room doesn't count), a Medicare-certified facility, and a doctor's decision that she needs daily skilled care.
Here is what Original Medicare charges in 2026, per Medicare.gov:
| Days in a benefit period | What she pays |
|---|---|
| Days 1 to 20 | $0 a day, after the $1,736 hospital deductible |
| Days 21 to 100 | $217 a day |
| Day 101 and after | All costs |
That $217 a day adds up to about $6,500 for a 30-day month. A Medigap policy or other coverage may pay some or all of it, so check her policy.
A benefit period starts when she is admitted as an inpatient to a hospital or skilled nursing facility. It ends after she has gone 60 days in a row without inpatient hospital care or skilled care in a nursing facility. A new benefit period can bring a new 100 days, but she would need to meet all the rules again, including a new three-day hospital stay.
What happens when Medicare stops paying
Medicare does not pay for long-term care, meaning help with bathing, dressing, eating and using the bathroom when that is the main care someone needs. Medicare.gov says so directly. When skilled coverage ends, families usually take one of these paths.
She stays in the same nursing home and pays privately. Ask the business office for the daily private-pay rate in writing, and what it includes. On Lilisity's nursing home cost pages, each state shows CareScout's 2025 median monthly costs and the private rates that nursing homes in that state publish.
She stays and applies for Medicaid. Medicaid pays for long-term nursing home care for people who qualify on income, assets and care needs. Each state runs its own program and sets its own rules, so call your state Medicaid office or ask the nursing home's business office who handles applications. The nursing home must be certified to take Medicaid. Ask early whether her bed is a Medicaid bed, or whether she would have to move rooms or buildings once Medicaid starts paying.
She uses long-term care insurance or VA benefits. If she bought a long-term care policy, find it now and call the insurer. A veteran or a surviving spouse may qualify for a VA pension with Aid and Attendance. Our VA Aid and Attendance estimator gives a rough monthly amount.
She moves to assisted living or goes home with help. If she needs daily help but not a nurse every day, assisted living may fit. Medicare won't pay for that either (why Medicare doesn't pay for assisted living). If she goes home, ask whether she qualifies for Medicare home health visits, and who will cover the hours in between.
Our Paying for Senior Living guide has a budget worksheet and covers each of these options in more detail.
How to pick a nursing home for a longer stay
A place that was fine for two weeks of rehab may not be where you want her for months or years. If you are choosing now, or deciding whether she should stay, look at the right numbers.
Every nursing home page on Lilisity shows its ratings from CMS Care Compare, the federal program, republished without changes. Here is what to look at for a long stay:
| On the Lilisity page | What it tells you |
|---|---|
| Long-stay quality | How residents who live there for months do on measures like falls and pressure sores. This matters more now than the short-stay rating. |
| Health inspections | How the home did on recent state inspections. Read the deficiencies listed below it, and open the full reports. |
| Staffing and turnover | Nurse hours per resident each day compared with the state average, and how often nursing staff leave. |
| Provider type | Whether the home is certified for both Medicare and Medicaid. If Medicaid may pay later, this matters. |
A high short-stay rating means the home does rehab well. For a parent who will live there, the long-stay rating, the inspection details and the staffing tell you more about daily life. Then visit at a mealtime or in the evening, and ask the questions in our nursing home guide.
To compare homes near her, search Lilisity for nursing homes in her city.
If you aren't being heard
- Call your Long-Term Care Ombudsman. Every state has one, it's free, and ombudsmen help residents and families with problems in nursing homes. The Eldercare Locator (1-800-677-1116) can connect you.
- Call your State Health Insurance Assistance Program (SHIP) for free one-on-one Medicare counseling. Find your state's number at shiphelp.org or by calling 1-800-MEDICARE.
- For Medicaid planning, the home, or who can sign for your parent, talk to an elder law attorney.
A checklist for the next two days
- Ask: "Is the reason her coverage is ending that she isn't improving?"
- Ask whether she still needs skilled care to keep from getting worse, and for maintenance goals
- Find the Notice of Medicare Non-Coverage and note the appeal deadline
- Call the number on the notice before noon the day before coverage ends
- Ask the business office for the private-pay rate and whether she can stay on Medicaid
- Look up the home's long-stay rating, inspections and staffing on Lilisity
- Call the ombudsman or SHIP if you need help
Sources
- CMS, "Jimmo Settlement": https://www.cms.gov/medicare/settlements/jimmo
- CMS, "Frequently Asked Questions Regarding Jimmo Settlement Agreement": https://www.cms.gov/center/special-topic/jimmo-settlement/faqs
- Medicare.gov, "Skilled nursing facility (SNF) care" (2026 costs and coverage rules): https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
- Medicare.gov, "Getting Started: Medicare & Skilled Nursing Facility Care" (benefit periods, fast appeals, SHIP): https://www.medicare.gov/publications/11359-Medicare-Skilled-Nursing-Facility-Care-Getting-Started.pdf
- Medicare.gov, "Long-term care": https://www.medicare.gov/coverage/long-term-care
- Medicare.gov, "Fast appeals": https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/fast-appeals
- Medicaid.gov, "Nursing Facilities": https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/nursing-facilities
- VA.gov, "Veterans Pension rates": https://www.va.gov/pension/veterans-pension-rates/
- CMS Care Compare, nursing homes: https://www.medicare.gov/care-compare/
- Lilisity nursing home costs by state (CareScout Cost of Care Survey 2025 medians and published private-pay rates, October 2026): https://www.lilisity.com/costs/
- Eldercare Locator (Administration for Community Living): https://eldercare.acl.gov/
- SHIP national technical assistance center: https://www.shiphelp.org/
