Many people believe that Medicare will cover most or all the cost of long-term care (LTC) for everyone, but that’s simply not true. Let’s take a closer look at what Medicare does and does not cover.
What is Long-Term Care?
First, what does “LTC” even mean? LTC refers to the assistance that a person needs throughout the day when their health is compromised and their expected need of care is more than 90 days. You may need physical assistance with activities of daily living (ADLs) which are transferring, toileting, bathing, dressing, eating, and continence or supervision due to a cognitive impairment. This assistance could be due to the frailty of aging, accident, injury, or cognitive impairment like Alzheimer’s. LTC mainly consists of unskilled, non-medical care also known as custodial care. Most people who need LTC receive care at home, while others do need to move to an assisted living facility or nursing facility.
Medicare does NOT cover custodial care if that’s the only care you need. Most nursing home care is custodial care. Medicare plays a small role in funding care because of strict eligibility and coverage limits.
What Does Medicare Part A Pay For?
Medicare Part A is hospital coverage and pays for short-term skilled care in a skilled nursing facility (SNF) following a qualified hospital stay. A SNF is different than a regular nursing home in that it provides skilled nursing and rehabilitation services.
For Medicare Part A to cover skilled nursing care, patients must meet all of the following conditions:
- You were hospitalized for at least 3 consecutive days (plus the day of discharge) before admission to the nursing facility.
The time you spend at the hospital under observation or in the emergency room before you’re officially admitted does NOT count toward the 3-day qualifying inpatient hospital stay, even if it involves being there overnight.
- You need skilled services for an ongoing condition that was treated during your hospital stay or a new condition that started while you were getting care at the SNF for the ongoing condition.
- A doctor certifies that you need skilled nursing services daily and the services, as a practical matter, can only be given when you’re in a SNF.
- You’re admitted to a Medicare-certified SNF within a short period of time (generally 30 days) of leaving the hospital.
- Care must be restorative in nature, and you must be improving. Once you’re considered “stable” Medicare stops paying.
- Skilled services must be reasonable and necessary for the diagnosis or treatment of your condition.
If all of these conditions are met, Medicare only pays 100% of the cost for the first 20 days and then you are required to pay co-payments for days 21-100. For days beyond 100, you pay the full cost for services.
Medicare will not pay for any part of a patient’s stay in a skilled nursing facility or any other facility if the services received are primarily custodial or personal in nature. Even though most nursing home admissions come from hospitals, not all of these accept Medicare. For those over 65, a hospital stay may have been less than 3 full days or there may not be a need for skilled care. Even if a person qualifies for Medicare coverage, they usually qualify for much less than 100 days. The average coverage is about 23 days and so few people can depend on Medicare to pay for any substantial skilled care costs.
What Does Medicare Part B Pay For?
Medicare Part B is medical coverage that covers some part-time/intermittent home health care when the following conditions are met:
- You must be “home-bound” which means you’re normally unable to leave your home, but if you do it requires a major effort.
- A doctor must certify that you need one or more of the following: intermittent skilled nursing care (other than drawing blood), physical therapy, speech therapy, or continued occupational therapy.
- You’re under the care of a doctor and you’re getting services under a Plan of Care established and reviewed regularly by a doctor.
- The care must be intermittent or part-time, no full-time home care is paid for by Medicare.
- The care must be provided by a Medicare-certified home health care agency.
- A health care professional must document that they’ve had a face-to-face encounter with you within required timeframes and that the encounter was related to the reason you need home health care.
To determine if you’re eligible for home health care, Medicare defines “intermittent” as needing skilled care fewer than 7 days/week, daily for less than 8 hours each day, and 28 or fewer hours each week (or up to 35 hours/week in some limited situations) for up to only 21 days. If you’re expected to need more than intermittent skilled care over an extended period, you wouldn’t qualify for home health benefits.
What Does Medicare Advantage (Part C) Pay For?
Medicare Advantage (MA), also known as Medicare Part C, combine the benefits covered by Medicare Part A and Part B into one plan sold by a private insurance company. The policy must cover at least the same level of coverage as Original Medicare. The private insurance company would handle your benefits and claims instead of the federal government.
As of recently some MA plans are offering benefits to help people live as independently as possible. The Centers for Medicare and Medicaid Services (CMS) allow MA plans the option of offering some home care coverage, but CMS didn’t make it mandatory. It’s up to the insurance provider to choose the benefits and what programs may include them. Some MA plans may offer benefits like:
- Transportation to doctor’s appointments and pharmacy
- Grab bars in home bathrooms
- Meal prep and delivery
- Caregiver support services
- Pest control
- Adult day care
Medicare Advantage-covered home care services can be quite difficult to qualify for, will be determined by your plan, and will be limited to a certain number of hours per month or year. For instance, a MA plan may allow 24-96 hours per year of in-home support valued at $50-$300 per month. These benefits are NOT comprehensive for LTC needs where someone may need assistance eight hours a day, but they are complementary to LTC insurance benefits.
Original Medicare and MA plans don’t include the cost of room and board or assistance with ADLs in an assisted living facility. To access benefits, you don’t have to need help with at least 2/6 activities of daily living (ADLs) or a cognitive impairment like you do with an LTC insurance policy. Every MA plan is different, and the plan will make the determination if in-home care is a service is available to you. The best way to determine if a plan has a provision for home care services is to reach out to your MA plan customer service number on the back of your medical card.
The Bottom Line
The coverage and benefits provided by Medicare and Medicare Advantage are NOT comprehensive if you need true LTC services, leaving most of the costs up to the patient and that’s where LTC insurance is beneficial. Medicare is intended to cover services that will help an older adult recover from a short-term medical problem. It was never intended to extend coverage for people with chronic care ongoing needs. It’s best to plan ahead and figure out how you will fund your LTC needs. An LTC insurance policy could be a good solution for you to cover your extended care needs. It helps pay for extended care at home, assisted living, nursing facility and pays for custodial and personal care.