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To what extent will Medicare cover long-term care?

Alex Guerrero // August 27, 2021

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Like many Americans, when the need for long-term care first struck my family, we were fairly ignorant about the subject – and especially the part about how to pay for it. We mistakenly assumed Medicare would pay for all of my grandmother’s care needs.

In the end, our family’s solution felt like putting together a puzzle. We relied upon multiple family members, respite care providers and home care professionals to provide my grandmother the care she required.

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The financial resources to pay for care also changed over the years. We combined Medicare’s assistance with a veteran’s aid program and over time, she became eligible for an increasing level of public assistance. Ultimately, we were fortunate to be able to provide for my grandmother in the location of her choosing. But it wasn’t easy, and it was definitely a confusing journey.

In hindsight, our confusion about how Medicare works with long-term care shouldn’t have surprised me, as I was unaware of even the basic terminology associated with long-term care.

And sadly, I know from my own experience talking with hundreds of families over the years, that most Americans end up facing the prospect of long-term care without even this basic understanding. They find themselves trying to problem solve before they’re even familiar with the problems.

The good news is that while Medicare’s role in long-term care is complicated, you can head off much of the headache that comes with the financial burden of long-term care by understanding these basic concepts:

The basics of paying for long-term care

Custodial care refers to personal care given to individuals to help them with activities of daily living (ADL), which include bathing, dressing, and transferring themselves from seated to standing or in and out of bed. Also known as non-medical carecustodial care can be, and frequently is, provided by persons without professional medical training.

Skilled care, on the other hand, requires the provider to have professional medical training and licenses. In a home environment, the distinction between who is providing these types of care is fairly clear. In a hospital environment, it is less evident. Nurses, for example, provide both medical and custodial care at the same time, especially in smaller hospitals.

In the past, the simplest test to determine whether Medicare would or would not pay for care was to consider whether the care being provided was custodial/personal care or medical/skilled care. Up until a recent announcement in regards to Medicare Advantage (MA), Medicare would not cover the custodial care, but would pay for skilled care (or at least a portion of it). That said, original Medicare will still only pay for skilled care (in part), but the rules of long-term care are more relaxed for MA.

In April of 2018, the Centers for Medicare and Medicaid Services (CMS) made policy changes that allow Medicare Advantage plans to cover supplemental healthcare benefits. Previous to this announcement, benefits of “daily maintenance” were not covered under MA. However, starting in 2019, MA plans are able to offer healthcare benefits that better the functional impact of health issues or reduce the need for the usage of health and emergency services.

The intention is to better the quality of a MA recipient’s life and for them to have better health outcomes. Therefore, a variety of home and community-based services are available on some MA plans. But uptake of this provision among MA insurers has been fairly slow. As of 2021, only 6% of MA plans provide coverage for in-home support or bathroom safety provisions.

Long-term care scenarios

Unfortunately, these seemingly uncomplicated distinctions become more complicated, especially as the patient’s need for care changes from temporary to long-term.

For Original Medicare to pay for care provided in the home, it must be medical care, prescribed by a doctor, and on a part-time basis. The individual must also be “confined,” which means they are unable to leave their home without assistance. For Medicare Advantage, it is more lenient, but still, a licensed provider needs to recommend the services and deem them medically necessary. (This holds true for all supplemental health care benefits to be provided by Medicare Advantage).

In adult daycare, most, if not all of the care being provided is considered non-medical – and therefore, Original Medicare does not pay for it. However, there are now adult day health care (ADHC) centers that provide medical care as well as non-medical. In these environments, if the care is prescribed and medically necessary, it falls within Medicare’s coverage guidelines. In addition, starting in 2019, some Medicare Advantage plans may cover adult day care under the new supplemental health care benefits.

The same applies to assisted living communities, which have, over time, increasingly offered medical services. Original Medicare, and most likely, Medicare Advantage, will pay for those services, but not for the costs of room and board.

Other long-term care benefits that may be provided through supplemental healthcare benefits via Medicare Advantage plans include respite care, meal delivery, and both medical and non-medical transportation. As of 2021, transportation and meal benefits are much more common on Medicare Advantage plans than in-home support services.

Skilled nursing facilities rules more complex

The rules involving Medicare and nursing homes or skilled nursing facilities are more complex.

Original Medicare and Medicare Advantage will pay for the cost of skilled nursing, including the custodial care provided in the skilled nursing home for a limited time, provided 1) the care is for recovery from illness or injury – not for a chronic condition and 2) it is preceded by a hospital stay of at least three days.

For the first 20 days, Medicare will pay for 100% of the cost. For the next 80 days, Medicare pays 80% of the cost. Skilled nursing beyond 100 days is not covered by Original Medicare.

Individuals who have a Medicare Advantage plan have at least the same coverage as mentioned above, and perhaps, have additional coverage. In addition, persons with certain types of Medicare supplemental insurance can get additional assistance towards defraying the cost of nursing home/skilled nursing care. Some plans will cover 100% of the coinsurance payment required by Medicare. This means that between Medicare and the Medigap plan, 100% of the cost of skilled nursing for 100 days will be covered.

Beyond Medicare assistance

Although Original Medicare’s overall benefits are limited for long-term care, Medicare Advantage is evolving. In addition, there are many other state and federal public assistance options that can help. There are financial resources from non-profits, foundations, and the Veteran’s Administration as well as private loan options that can help.

Some people choose to purchase private long-term care insurance, which will cover varying amounts of the cost of long-term care if and when you need it. This is a decision that should be made in conjunction with an analysis of your overall financial picture, as long-term care insurance is fairly expensive.

Medicaid is a useful means of paying for long-term care for low-income seniors and those who have exhausted their assets. In fact, six out of ten nursing home residents are covered by Medicaid, usually in addition to Medicare. Based on functional and financial need, assistance with a variety of long-term care needs is provided through state Medicaid plans and home and community-based services (HCBS) Medicaid waivers. This support – based on your Medicaid eligibility – could come in the form of personal care assistance, companionship care, respite care, adult daycare, meal delivery, nursing home care, and more.

As always, it’s well worth your time to research online resources – including this Resource Locator Tool – to determine whether you or your loved one are eligible for resources that can help pay for assisted living or pay for home care.

Select your state on this map to see how Medicaid can provide assistance in conjunction with your Medicare coverage.

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kim wheeler
2 years ago

My mother is 87 years old she been in and out of the hospital here lately . She lives by her self but my sister lives next to her. We think it time to look at elder care, or long-term care. We are not sure what to do at this time. Can you help with what we should do at this time? Thank you.

Maurie Backman
2 years ago
Reply to  kim wheeler

Clearly, this is a difficult situation for you. Unfortunately, the cost of long-term care can be prohibitively expensive, so I suggest that you spend some time researching your options and seeing what makes the most sense logistically and financially. You say your sister lives next door to your mother. Perhaps a part-time home health aide is a good solution, particularly if your mother is reasonably functional on her own and you don’t want to go to the extreme of nursing home care (which will be considerably more expensive than a home health aide).

Generally speaking, Medicare won’t cover long-term care, though if your mother has an Advantage plan, there may be some coverage at play. See what your options are in that regard. And also, I suggest speaking to your mother and asking what she wants. Many seniors prefer to age in place than pack up and move to facilities they’re unfamiliar with.

Also, you don’t indicate why your mother has been in and out of the hospital but if it’s due to a medical issue, she may be entitled to some in-home care that is covered by Medicare.

So to summarize:
Review your mother’s health benefits and see what she’s entitled to
Research options and run numbers to get a sense of your long-term care costs
Talk to your mother about her needs and wants in this situation

I wish you the best of luck.

Joyce Crowder
2 years ago

My mom recently broke her leg requiring surgery and rehab. Prior to this, she was completely self reliant. As a result of surgery, she is now on dialysis and soon to be discharged from snif. She has 2 small FEMA homes. One at our land and one on my brothers land. In order to qualify for assistance in the future for a long term facility, she will need to sell one of these tiny homes. Is that correct?

Josh Schultz
2 years ago
Reply to  Joyce Crowder

She will probably have to sell or transfer the home that isn’t her primary residence, or it will count as an asset and disqualify her from Medicaid eligibility (which she probably needs to pay for her long-term care). There are many rules surrounding transferring and spending down assets, so it’s probably a good idea to speak with an elder attorney regarding these issues:

2 years ago

Scenario: 83 yr old mother wc bound, no vision right eye, mild vascular dementia, daily eye drops– incontinent She only has $1450 per month– savings used up no property non VA– How will she be able to have assistance the remainder of her days? She makes too much money for Medicaid Presently lives in an assisted living Her medical bills are paid up–

leigh mckenzie
2 years ago

Why does Medicare penalize our elderly for the rest of their lives after having a late enrollment in Medicare Part D– Convicted criminals are not penalized for life– why are our elderly citizens?

Dan Harrington
2 years ago

Can My 89 yr. old mother recieve veteran benifits through her dead husband she divorced in1977 ?

Josh Schultz
2 years ago
Reply to  Dan Harrington

You should probably address this question to the Department of Veteran’s Affairs or the VA.

2 years ago

How can we advocate for better care of our elderly?
People work their ENTIRE lives , pay into SS .Then when they need the benefits the most .they are not there .Medicare pays nothing for Long Term care facilities especially if its a mental/ brain disease .You spend EVERY dime you earned on housing from 6 to 10000 a MONTH !
When it’s gone you try to go on Medicaid because now you’re completely broke .But you make TOO much on SS to qualify ..then comes the hoops ..
Our system is totally robbing and letting our elderly down .
Its a broken system .So sad .

2 years ago

My 90 year old mother had hip surgery they are sending her to skilled nursing and I would like to care for her at home, after I get my house ready can I bring her home and will Medicare pay for the bed and medical help she will need at home

Josh Schultz
2 years ago
Reply to  Cece

This article should answer your some of your questions about what Medicare will cover once your mom returns home:

As a general matter, Medicare would cover intermittent ‘skilled’ care (such as nursing care, physical and occupational therapy) and limited assistance with daily activities (e.g. cooking, cleaning) while she is receiving skilled services. Medicare should cover her bed if it is a medically necessary piece of durable medical equipment.

Note that Medicare will no longer cover any help with daily activities once your mother no longer needs ‘skilled’ services. At that point (or beforehand), she may want to research whether she is eligible for Medicaid.

Linda C McCray
7 months ago

Medicare rules for beds with rails

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