Does Medicare Cover Long-term Care?

Did you know that nearly three-quarters of people who are 65 and older will eventually need long-term care sometime in the future? These days people are living longer, and that increases the chances that you may need long-term care down the road.

Considering the cost of long-term care, this figure is worrisome for many people. The national cost of long-term care in 2016 was $6,844/month for a semi-private room. Further complicating this picture is that many Medicare beneficiaries are completely unaware that Medicare does not pay for long-term care.

Here are the important facts about Medicare and long-term care.

Long-term Care vs Skilled Nursing Facility Care

One of the critical things to know in terms of your Medicare coverage is that skilled nursing facility (SNF) care is not the same as long-term care. Medicare will cover some SNF nursing care costs on a short-term basis. It is designed to help you recover so that you can return to caring for yourself.

Examples of skilled nursing facility care might be care received after a stroke or a hip replacement. You are ready to leave the hospital, but you still need skilled nursing care, so your doctor transfers you from the hospital to the SNF.

To qualify for SNF care, you must have an inpatient stay in a hospital for at least 3 days before you get transferred to the skilled nursing facility. The SNF must also be certified by Medicare. Your care there needs to be related to the condition for which you were hospitalized.

Your physician needs to document his opinion that skilled nursing will help you improve. You cannot be in a state of health decline. There needs to be a reasonable expectation that after your SNF care, you’ll be able to return home.

Medicare Benefits for Skilled Nursing

If you are eligible for a covered admission to a skilled nursing facility based on doctor’s orders after a hospital stay, here is what Medicare covers:

  • 100% of the allowable charges for Days 1 through 20
  • 80% of the allowable charges for Days 21-100.
  • No coverage after Day 100 in any single benefit period.

Medicare Part A benefits are measured in benefit periods. A “benefit period begins on the day that you are admitted to the hospital. It ends once 60 days have passed after you’ve completed an inpatient stay. It is possible to have more than one benefit period in a single calendar year.

Since Part A (and B) have deductibles and copays that you are responsible for, many individuals choose to enroll in a Medigap plan when they first become eligible for Medicare. These plans help to fill in the gaps in Medicare.

Long-term Care

Long-term care, on the other hand, is for when you are no longer able to live on your own. For example, if you are having difficulty with tasks of daily living such as bathing, eating, dressing, and getting in and out of bed, you are not likely to recover to independent living.

This is a need for long-term care in a nursing home or assisted living facility. Medicare does not cover your stay – or your monthly “rent” – in a long-term care facility.

Oftentimes, long-term care is actually what we call custodial care, or help with basic tasks. Unfortunately, Medicare will not cover custodial care if that’s the only care that you need. Sometimes a home health care aide who is there to provide therapy services may assist you with custodial care as part of their visit, but If there is not a medical need for the home health care, it won’t be covered.

If you have a need for long-term care and have exhausted your personal funds to pay for that care, you can apply for Medicaid for assistance. Medicaid is a federal and state program which offers help with nursing home costs for people with low incomes.

Medical Care During a Long-term Care Stay

While Medicare doesn’t pay for the cost of your long-term care facility, you do still have coverage for medical care. Your physician appointments and lab-work and medical supplies will still be covered by Medicare Part B.

If you go into the hospital, Part A pays for your inpatient stay.  doctor visits, x-rays and lab tests, and durable medical equipment are covered under Part B. Your Part D drug plan will also still cover your prescription drugs even while you are in an assisted living or nursing home environment. However, you should check to see if the pharmacy in your nursing home (or that delivers to your nursing home) is in the network for your Part D plan.

What about Home Health Care?

Medicare limits the benefits that you can receive at home. If your doctor certifies that you are homebound and that you need specialized care on a part-time basis, Medicare may cover home health care for this. Medicare requires that this care is expected to help you recover within a reasonable amount of time.

The home health care needs to be short-term, usually 21 days or less. In general, Medicare can pay for up to 28 hours of weekly home health care services, including nursing and physical therapy.

Caregiving services by a home health aide are usually covered if they support skilled nursing care. For example, if the home health aide changes dressings or administers medications, that care is likely covered.

Just remember that if the home health care is limited to primarily custodial care, Medicare is not likely to cover it.

Hospice

If you are diagnosed to be terminally ill, with 6 months or less to live, then you can qualify for hospice care under Medicare Part A. You must receive this care at a certified hospice facility.

While you are in hospice, the rules are different. Medicare will allow custodial care. It’s common for Medicare to pay for hospice-certified home health aides.

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