How to Get Medicaid to Pay for a Private Room at a Nursing Home

Summary
Medicaid will only pay for a private room if it is medically necessary, or in a handful of states, if a private room is the only room available within the nursing home. In all other cases, Medicaid will only pay for a semi-private (shared) room. Some states, however, allow another way for Medicaid-funded nursing home beneficiaries to reside in a private room. This is via family supplementation, which allows a family member to pay the difference in cost between a shared room and a private room. In other words, the family can “upgrade” their loved one to a private room.

Nursing Home Medicaid & Private Rooms

Medicaid will pay for nursing home costs, including room and board, for anyone who meets the financial and functional eligibility requirements. It is an entitlement program, which means states cannot limit the number of persons for whom they will pay for care. Medicaid routinely pays for shared nursing home rooms, and generally speaking, does not pay for private rooms. However, if the need for a private room is medically necessary, Medicaid will pay for a private room. Once it is no longer medically necessary, Medicaid will no longer pay for a private room.

What it Means to be “Medically Necessary”

The need for a private nursing home room is considered medically necessary if the resident requires isolation for their own health or that of their fellow residents. Isolation may be required due to infections and contagious disease, psychotic episodes, or behavior that may result in physical harm to themself or others in the nursing home. A private room may also be deemed medically necessary if the symptoms or treatments of one’s condition will likely distress or disturb a roommate. The exact criteria for what is considered medically necessary varies slightly based on the state in which one resides.

In addition to the need for a private room to be medically necessary, the nursing home resident’s doctor must order a private room on this basis.

Exception: If a Shared Room is Not Available

In a limited number of states, Medicaid will pay for a private room if there is not a semi-private (shared) room available within a nursing home facility. In other words, the only rooms available are private rooms. North Carolina is one such state that allows this exception.

Family Supplementation for Private Rooms

If Medicaid will not cover the cost of a private room because it is not medically necessary, family supplementation, also called income supplementation, or sometimes private room supplementation, may be an option. This allows a nursing home resident’s family, or another loved one, to “upgrade” the resident to a private room by paying the difference between a semi-private room (which Medicaid will pay for) and a private room. The resident or their family must request in writing that the nursing home provide a private room with the understanding that the family will be responsible for paying the extra cost directly to the nursing home.

Unfortunately, not all states allow family supplementation. Among some of the states that do allow it are California, North Carolina, Missouri, Montana, and Ohio.