Medicare vs Medicaid Nursing Home Georgia: What Each Actually Covers

The Confusion That Costs Georgia Families Thousands

Most families discover the difference between Medicare and Medicaid the hard way — when a parent is in a nursing home and the bills suddenly change. Medicare pays for the first few weeks, the family assumes it will keep paying, and then a notice arrives: Medicare coverage is ending, and the facility wants $8,821 per month at the private-pay rate.

These are two completely separate programs with different eligibility rules, different coverage, and different purposes in a nursing home setting.

What Medicare Covers in a Georgia Nursing Home

Medicare Part A covers short-term, post-acute rehabilitation — not long-term custodial care. The coverage requires a qualifying hospital stay of at least three consecutive inpatient days (observation status doesn't count).

After that qualifying stay, Medicare covers:

• Days 1–20: Full coverage of a semi-private room, meals, skilled nursing care, physical therapy, occupational therapy, and speech therapy. No copay.
• Days 21–100: Coverage continues, but with a daily copay of $217 per day (2026 rate). Most families purchase a Medicare Supplement (Medigap) policy to cover this copay, or the parent's Medicare Advantage plan may cover it partially.
• Day 101 onward: Zero Medicare coverage. The patient is responsible for the full private-pay rate.

The catch: Medicare can stop paying before day 100 if the patient no longer needs skilled care. Medicare does not require measurable improvement: skilled maintenance care, including care that prevents or slows decline, can qualify when it is medically necessary. If the facility says coverage is ending, ask it to identify the skilled-care basis for the decision and use the appeal process promptly.

When coverage ends, the facility must issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the last covered day. Families can appeal this determination through a Quality Improvement Organization (QIO) — and the appeal keeps coverage running while it's reviewed.

What Medicare Never Covers

Medicare does not pay for:

• Long-term custodial care (help with bathing, dressing, eating, toileting when the need is permanent rather than rehabilitative)
• Assisted living or personal care homes
• Non-medical home care
• Room and board beyond the rehabilitation period

This is the coverage gap that blindsides families. A parent who needs nursing home care indefinitely — because of advanced dementia, multiple chronic conditions, or severe physical dependency — cannot rely on Medicare for a single day of it.

What Medicaid Covers in a Georgia Nursing Home

Georgia's Long-Term Care Medicaid (institutional Medicaid) is the primary public payer for long-term nursing home stays. Unlike Medicare, it covers custodial care indefinitely — for as long as the resident meets the clinical and financial requirements.

Medicaid pays the facility a negotiated daily rate that covers:

• Room and board (semi-private)
• Nursing care (24-hour)
• Meals, housekeeping, laundry
• Medical supplies and equipment within the facility

The resident contributes almost all of their monthly income as "patient liability" — essentially a copay. Georgia allows the resident to keep a $70 monthly Personal Needs Allowance (PNA) for personal expenses. If the resident has a spouse living in the community, a portion of the income can be diverted to the spouse (up to $4,066.50 per month in 2026).

Medicaid Eligibility in Georgia

Qualifying for nursing home Medicaid involves two separate determinations:

Clinical eligibility: The applicant must meet a Nursing Facility Level of Care (NFLOC) standard, verified through a clinical assessment showing significant functional dependency requiring 24-hour skilled nursing supervision.

Financial eligibility:

• Gross monthly income at or below $2,982 (2026). If income exceeds this, a Qualified Income Trust (Miller Trust) must be set up to shelter the excess.
• Countable assets at or below $2,000 for a single applicant. Exempt assets include the primary home (up to $752,000 equity), one vehicle, personal effects, and term life insurance.

If the applicant is married, spousal impoverishment protections allow the community spouse to retain $32,532–$162,660 in countable assets and receive income diversion if their own income falls below the state minimum.

The Transition Point Families Need to Plan For

The critical handoff happens when Medicare rehabilitation coverage ends and the parent still needs nursing home care. The options at that point:

1. Private pay at the facility's full rate until assets are spent down to the Medicaid threshold
2. Long-term care insurance if the parent has a policy with remaining benefits
3. Medicaid application — which should be filed well before Medicare runs out, since federal rules allow Georgia's DFCS up to 45 days to process the application

Families who wait until day 80 of Medicare to start thinking about Medicaid face a gap where they're paying $8,821+ per month out of pocket while the application processes. Starting the Medicaid application during the first week of Medicare coverage gives the most runway.

Georgia-Specific Complications

The 60-month look-back. Any assets transferred, gifted, or sold below fair market value in the five years before the Medicaid application triggers a penalty period. During the penalty, Medicaid won't pay — the family covers the nursing home bill.

Estate recovery. After the Medicaid recipient dies, Georgia can seek reimbursement from their estate. DCH Rule 111-3-8-.02 defines the recoverable estate broadly to include some property passing outside probate, so TOD deeds, Lady Bird deeds, and POD bank accounts should not be described as automatic shields even when they avoid probate.

The $25,000 exemption. Estates valued at $25,000 or less are entirely exempt from Medicaid estate recovery under Georgia law.

The Georgia Care Decision Guide maps the full Medicare-to-Medicaid transition timeline, including Miller Trust setup, asset protection strategies, and the specific forms needed for a Georgia nursing home Medicaid application.

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