What to Know About Medicare and Long-Term Care

HEALTH - patient with doctor Photo Credit: Sheff

As seniors review their Medicare coverage, a key area of concern is often “What is my coverage if I need to go into a nursing home or a skilled nursing facility? Will Medicare cover in-home care? And if I need long-term care, is that part of the Medicare benefit?”

While it’s always best to contact Medicare directly to verify coverage and other particulars, the following frequently asked questions about Medicare and Long-Term Care (LTC) provided by MedicareFAQ, a non-government learning resource center for Medicare recipients, will help inform you about the various options and coverages. (Read the full article here.)

To learn more about Medicare, visit https://www.medicare.gov or download the Medicare publication. You can apply online for Medicare on Social Security’s website.

What does Medicare consider long-term care?

Long-term care (LTC) is a phrase that encompasses both medical and custodial care for disabilities and chronic conditions. LTC can be provided at home or in a facility, and can include a range of assistance from as simple as meal delivery or as robust as occupational therapy.

Does Medicare pay for Long-Term Care?

No, Original Medicare does not pay for long-term care if it is the only care you need—for example, help with daily activities or custodial care. In those situations, you are responsible for the cost. However, if you have a chronic illness or disability that requires long-term care, Original Medicare will pay for rehabilitative care and skilled services.

Medicare will also provide coverage if you have spent three consecutive days as an inpatient in a hospital and then are transferred to a skilled nursing facility or nursing home for observation. However, if you are sent to another type of facility, other rules would apply.

Is there a coverage time limit for a nursing home or skilled nursing facility stay?

Medicare provides 100% coverage for benefits for days 1-20. From day 21 to day 100, you would be responsible for a daily copayment. After 100 days, Medicare no longer provides any benefits for ongoing care at a nursing home or skilled nursing facility and you would be responsible for the full cost until your resources have been exhausted. At that point, you can apply for Medicaid.

Will Medicare pay for in-home care?

Yes. With Medicare, you pay zero for home health services and 20% of the Medicare-approved amount for durable medical equipment (DME), provided you are eligible for in-home care: you are under the care of a doctor, and one or more of the following applies:

  • You are homebound
  • Require occasional skilled nursing care
  • Require services such as physical, language or occupational therapy. The therapy must be reasonable, and the condition is expected to improve

All services must be provided by a Medicare-approved Home Health Agency. Typically, the home health agency coordinates all services that your medical provider orders.

Will Medicare pay for care received in an assisted living facility?

Medicare does not provide coverage for services, referred to as custodial care (bathing assistance, medication management, meals, and transportation), received at an assisted living facility.

Does Medicare pay for acute care?

Yes. If you suffer an acute, or short-term sudden illness or injury (defined as lasting no more than 12 weeks), you will be covered by Medicare.

Services can be provided in a hospital, urgent care center, nursing home or skilled nursing center. Surgical needs, the emergency room, and intravenous fluids all fall under the acute care umbrella, as do an evaluation by your healthcare provider, the intensive care unit and ambulance.

Does Medicare pay for long-term memory care?

Medicare does pay for memory care (Alzheimer’s or memory impairment) if it is received in a covered facility—for example, at a nursing home or skilled nursing facility. However, if you stay in an assisted living facility to receive memory care, Medicare will not provide coverage.

How does a Medigap policy work?

A Medigap policy will always cover what Original Medicare covers. If Original Medicare doesn’t provide any coverage, then the Medigap plan will not cover it either.

How much it covers depends on the letter plan. Example, Plan F will cover every out-of-pocket expense after Original Medicare pays its portion, and you pay nothing at the doctors and/or hospitals. However, Plan G covers everything except for the Part B deductible, which is $185 in 2019 and increasing to $197 in 2020. So with Plan G, you have to pay the $185 before all your plan benefits kick in.

When it comes to Medicare Advantage plans, there are some long-term care benefits available with some plans for in-home patient support and adult day care services, but not assisted living. For more information, read Medicare and Long Term Care Frequently Asked Questions and Does Medicare Advantage Cover Assisted Living?.

Photo Credit: Sheff

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