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Medicare and Long-Term Care: What’s Covered and What’s Not

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Medicare Basics

Medicare is divided into several parts:

  • Part A: Hospital Insurance
  • Part B: Medical Insurance
  • Part C: Medicare Advantage Plans (an alternative to Parts A and B, offered by private companies)
  • Part D: Prescription Drug Coverage

Each part offers distinct coverage; it’s important to understand these distinctions.

Medicare Coverage – Part A

Medicare’s coverage of long-term care is limited and primarily focuses on medical care rather than custodial care, which includes assistance with daily living activities such as bathing, dressing, and eating.

Part A covers inpatient hospital care, skilled nursing facility (SNF) care, hospice care, and some home health services. However, it only covers short-term care under specific conditions:

Skilled Nursing Facility (SNF) Care

Medicare Part A covers up to 100 days of care in a skilled nursing facility per benefit period, following a qualifying hospital stay of at least three days. This coverage is intended for patients who need skilled care such as physical therapy or nursing after a hospital stay, not for long-term custodial care (like help with bathing, dressing, or eating).

  • First 20 days: Fully covered by Medicare.
  • Days 21-100: Covered with a copayment ($200 per day in 2024).
  • Beyond 100 days: The patient is responsible for all costs.

Home Health Care

Medicare covers home health care services, such as intermittent skilled nursing care, physical therapy, and other related services. However, this coverage is for limited periods and is not intended to provide long-term care for chronic conditions.

Medical Need: The patient must require skilled nursing care, physical therapy, or speech-language pathology.

Homebound Status: The patient must be considered homebound, meaning it is extremely difficult for them to leave home.

Intermittent Care: The care must be part-time or intermittent, rather than full-time or long-term.

Covered services can include skilled nursing care, therapy, and medical social services. However, personal care (like help with bathing and dressing) is covered only if it is part of the therapy services received.

Medicare Coverage – Part B

Part B covers medically necessary services and preventive services. For long-term care:

Outpatient Services

Part B covers certain outpatient services that might be needed as part of long-term care, such as doctor visits and durable medical equipment (DME) like wheelchairs or walkers.

Home Health Services

Similar to Part A, Part B can cover additional home health services for those who qualify, but these services are also limited and not intended for long-term custodial care.

diagram of medicare

Medicare Coverage – Part C (Medicare Advantage)

Some Medicare Advantage plans offer broader coverage for services that might relate to long-term care:

Extended Home Health Services

More extensive than what original Medicare covers.

Custodial Care

Some plans may offer limited coverage for certain custodial care or support services, but this varies significantly by plan and is not typically comprehensive.

What Medicare Does Not Cover in Long-Term Care

While Medicare provides valuable support for short-term medical and rehabilitative care, it does not cover most long-term care costs, which many require over time. 

Custodial Care

Medicare does not cover custodial care, which includes assistance with activities of daily living (ADLs). Custodial care is a significant component of long-term care services provided in settings such as nursing homes, assisted living facilities, and in-home care for chronic conditions.

Long-Term Nursing Home Care

Long-term stays in nursing homes, where the primary services are custodial rather than medical, are not covered by Medicare. Once the initial period of skilled care and rehabilitation (up to 100 days) is over, patients are responsible for covering the costs of ongoing care. 

Assisted Living and In-Home Care

Assisted living facilities, which provide a mix of housing, personal care, and health services, also fall outside Medicare’s coverage. In-home care services for chronic conditions, such as non-medical assistance with daily activities, are not covered unless they are part of a covered home health care plan focused on rehabilitation.

caregiver assisting elderly wheelchair

Alternatives to Medicare for Long-Term Care Funding

Given the significant limitations of Medicare in covering long-term care, you should consider other funding options.

Medicaid

Medicaid, a joint federal and state program, provides more comprehensive coverage for long-term care than Medicare. It is designed for low-income individuals and can cover long-term nursing home care and some in-home and community-based services. However, you have to meet eligibility requirements.

Long-Term Care Insurance

Long-term care insurance is a private option that can cover a range of services such as custodial care in nursing homes, assisted living facilities, and in-home care. You have to buy this insurance before needing care and premiums can be expensive. Also, coverage terms vary widely.

Personal Savings and Assets

Some people use retirement savings, sell property, or use other financial resources to cover the costs of care, but this significantly impacts your financial security.

Veterans Benefits

Veterans may have access to long-term care services through the Department of Veterans Affairs (VA). 

Texans need to be aware that while Medicare provides some coverage for short-term skilled care and limited home health services, it does not cover long-term custodial care or extended stays in nursing homes. For comprehensive long-term care needs, you should investigate other options well before you need them. Wise Insurance can guide you on solutions to meet your healthcare needs.

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