Skilled nursing operators may have woken up Friday morning with another unexpected cash injection from the federal government, but nursing homes that rely primarily on Medicaid are still waiting for their share of the pie.

The Department of Health and Human Services (HHS) on Friday began sending out the last $20 billion chunk of a $50 billion relief package for Medicare providers.

The federal government in mid-April sent $30 billion to all operators that provide services under fee-for-service Medicare, with the exact amounts for each provider based on their reimbursements in 2019.

The payments — which one estimate pegged at $1.5 billion for skilled nursing homes — took some operators by surprise, as HHS began releasing the funds with little fanfare.

Providers were also required to agree to specific terms governing their use of the money within 30 days, or face the prospect of sending it back; Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma had previously described such money as coming with “no strings attached.”

HHS described that $30 billion infusion as an initial amount to tide providers over, with the $20 billion released Friday completing the Medicare stimulus. As with the first round, some providers will automatically receive their cash, while others will be required to submit revenue information to HHS online in order to obtain the payments.

“Payments will go out weekly, on a rolling basis, as information is validated, with the first wave being delivered at the end of this week,” HHS noted, referring to April 24.

Those two Medicare stimulus rounds came from a $100 billion fund for health care providers set up by Congress through the $2 trillion CARES Act; a subsequent stimulus package, passed this past week, added $75 billion more to that total available funding.

But so far, only Medicare providers have seen any direct relief through the program, with operators that derive most of their revenue through Medicaid — such as many nursing facilities that care for long-term residents — awaiting funding through an upcoming tranche promised by Verma.

Medicaid covers more than 60% of all nursing home residents across the nation. These residents typically represent the most vulnerable members of any nursing facility community, with profound daily care needs that require around-the-clock institutional care.