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.
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.
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.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
