The hidden costs of nursing home care: 9 fees nobody mentions on the tour
The number quoted on a nursing home tour is almost never the number on the first monthly statement. Most US nursing homes price the room and basic care, then charge separately for a series of services that most residents will eventually need: incontinence supplies, physical therapy after a fall, transportation to a specialist appointment, even holding the bed during a hospitalisation. None of this is hidden in a legal sense — it's all in the admission agreement — but it's rarely raised on a tour, and the cumulative effect can add $1,500 to $3,000 a month. This post walks through the nine line items families most often miss.
1. Level-of-care surcharges
Most homes price by acuity. The base daily rate usually covers a 'basic' resident: ambulatory, mostly continent, no complex medical needs. Residents who need two-person transfers, wound care, IV medications, or are on a feeding tube typically move into a higher tier with a $20 to $80 daily surcharge. The tier can change month to month based on a clinical reassessment, and increases do not require new family consent. Ask: what triggers a tier change, and how is it documented?
2. Incontinence and personal-care supplies
Many homes pass through the cost of briefs, wipes, gloves and barrier creams as a flat $150 to $300 monthly supply fee, or itemise them on the invoice. Medicare does not cover these supplies in long-term care; Medicaid does in most states. Private-pay residents often discover this at month two when the first supply bill lands.
3. Physical, occupational and speech therapy co-pays
Medicare Part A covers therapy during a qualifying skilled-nursing stay (up to 100 days post-hospitalisation). After that, ongoing therapy is billed under Part B with a 20 percent co-insurance, with no out-of-pocket cap unless the resident has a Medigap policy. A resident doing three therapy sessions a week can run up $250 to $400/month in co-pays.
4. Bed-hold fees during hospital stays
If a resident is hospitalised, most facilities will hold the bed for 5 to 14 days — but at the full daily rate. For Medicaid residents, federal rules let states cover up to 7 bed-hold days; for private-pay residents, the cost falls on the family. A 10-day hospitalisation can mean a $3,000 bill for an empty bed.
5. The Medicare Part A day-21 cliff
Medicare covers 100 percent of the daily rate for the first 20 days of a qualifying skilled-nursing stay. From day 21 to day 100, the resident pays a daily co-insurance — $209.50 per day in 2026. That is over $6,200 a month, payable until day 100 or until the resident no longer meets the skilled-care threshold. Most families think 'Medicare covers 100 days' and only discover the cliff in week four.
6. Pharmacy mark-ups
Many nursing homes use a contracted long-term-care pharmacy with prices well above retail. Residents on Medicare Part D should confirm the contracted pharmacy is in their plan's network; out-of-network charges can quietly add $100 to $400 a month. Some families keep filling routine prescriptions at the resident's prior retail pharmacy and have them delivered.
7. Transportation and outside appointments
Non-emergency transport to specialist or dental appointments is typically billed at $50 to $150 round trip. Wheelchair vans are higher. Some homes require a staff escort at an additional hourly rate. Ask whether the home has on-site podiatry, dental and optometry — these visits often save several hundred dollars a year.
8. Private room upgrade
Quoted rates are almost always for a semi-private (shared) room. A private room typically adds $1,200 to $2,500/month. Medicaid rarely covers the upgrade. If the resident has a roommate who later moves out, some homes will keep them in the now-private room at the semi-private rate — others will require the family to either pay up or accept a new roommate.
9. Beauty salon, cable, phone and personal laundry
Small items, but they add up: $40 to $80/month for a haircut and styling, $20 to $40 for cable in the room, sometimes $30+ for personal laundry beyond two loads a week. The admission agreement should list every optional service and price.
Your rights on pricing
Under federal regulations (42 CFR 483.10), every certified nursing home must give residents a written list of all items and services included in the daily rate and a separate written list of items and services available at additional cost, with prices. You can ask for this before signing. The home must also give 30 days' written notice of any rate change.
Frequently asked questions
Authoritative sources
Figures, rules and claims in this post are drawn from these official and independent sources.
- Cost of Care Survey
Genworth Financial
- 42 CFR 483.10 — Resident rights
Code of Federal Regulations / eCFR
- Medicare skilled nursing facility care
Medicare.gov
- Long-Term Services and Supports state Medicaid rules
Medicaid.gov
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About this post
Written and reviewed by the Nursing Home Match editorial team. We update posts as the underlying rules and data change. This post is general information, not personal medical, financial or legal advice — always confirm details on Medicare.gov Care Compare or My Aged Care before making decisions.