How Medicare Covers Long-Term Care

With the aging population, it's crucial to grasp what Medicare does and doesn’t cover to plan effectively for the future. This article provides a comprehensive overview of Medicare’s long-term care coverage, helping you make informed decisions about your healthcare needs.

What is long-term care?

Long-term care refers to a variety of services designed to meet an individual's health or personal care needs over an extended period. These services can be provided at home, in the community, or in various types of facilities, such as nursing homes or assisted living centers. Long-term care is primarily focused on helping individuals with activities of daily living (ADLs) such as bathing, dressing, and eating.

Medicare’s coverage for long-term care

Medicare, the federal health insurance program for people aged 65 and older, and for some younger people with disabilities, offers limited coverage for long-term care services. Here's a detailed look at what is and isn't covered:

1. Skilled nursing facility (SNF) care

Medicare Part A covers care in a skilled nursing facility for a limited time under specific conditions:

• You must have a qualifying hospital stay of at least three days.
• You need to enter the SNF within 30 days of leaving the hospital.
• Your doctor must certify that you need daily skilled care, such as physical therapy or intravenous injections, which can only be provided in a SNF.

Medicare covers:

• 100% of the cost for the first 20 days.
• A copayment for days 21-100 (in 2024, this is $200 per day).
• No coverage beyond 100 days per benefit period.

2. Home health care

Medicare covers certain home health services if you meet specific criteria:

• You must be under the care of a doctor and receive services under a plan of care established and reviewed by a doctor.
• You must be homebound, meaning leaving home requires considerable effort.
• The services must be medically necessary, such as intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy.

Medicare covers:

• Part-time or intermittent skilled nursing care.
• Physical therapy, occupational therapy, and speech-language pathology services.
• Medical social services.
• Part-time or intermittent home health aide services (if you are also getting skilled nursing care or therapy).

3. Hospice care

Medicare Part A covers hospice care for terminally ill patients with a life expectancy of six months or less if they choose to receive palliative care rather than curative treatment.

Medicare covers:

• All items and services are needed for pain relief and symptom management.
• Medical, nursing, and social services.
• Certain durable medical equipment.
• Aide and homemaker services.
• Spiritual and grief counseling.

What Medicare does not cover

It's important to note that Medicare does not cover long-term care if that is the only care you need. This includes:

• Custodial care (personal care that does not require a medical professional), such as help with bathing, dressing, and eating.
• Long-term stays in nursing homes or assisted living facilities.

Alternative options for long-term care coverage

Given Medicare’s limited coverage, it's essential to explore other options for long-term care. These include:

• Medicaid: A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid covers long-term care services in nursing homes and sometimes at home or in the community.
• Long-term care insurance: This type of insurance policy helps cover the costs of long-term care beyond what is covered by Medicare and other health insurance.
• Personal savings: Many people rely on personal savings or investments to pay for long-term care services.

• Veterans benefits: Veterans may qualify for long-term care services provided by the Department of Veterans Affairs.

Planning for long-term care

Planning for long-term care involves considering your potential need for care, understanding the costs, and knowing your insurance options. Utilize resources like the Healthpilot website to explore different health insurance plans and find coverage that best suits your needs. Being proactive in your planning can provide peace of mind and financial stability in the long run.

Conclusion

Understanding how Medicare covers long-term care is crucial for effective planning and ensuring you receive the necessary care without unexpected expenses. While Medicare provides significant benefits, it has limitations regarding long-term care services.

Exploring additional coverage options and planning ahead can help you manage the financial aspects of long-term care and maintain your quality of life.