Many adults will need some type of long-term care in their lifetime. But it’s not always clear whether it’s covered or not. If you or a loved one have Medicare, you might be wondering about your options regarding long-term care should you need it down the road.
Here, we’ll address what type of long-term care is covered, who is eligible to receive coverage, and how to get help paying for it.
Before we discuss what Medicare covers, it’s important to know what long-term care means. Long-term care refers to a variety of services deemed necessary to take care of your health and medical needs over an extended period of time. This differs from short-term care, such as a visit to the doctor’s office or emergency room.
Here are the following long-term care services that Medicare covers:
Skilled nursing facilities
A skilled nursing facility (SNF) can provide medical or health-related services from a professional or technical staff to monitor, manage, or treat a health condition. Staff at an SNF include professionals such as:
Examples of when someone might need SNF care include:
- recovering from an acute health condition, such as a heart attack or stroke
- physical or occupational therapy after an injury or surgery
- care that requires intravenous medications, such as after a severe infection or long illness
Medicare Part A covers short stays at an SNF. Here is the breakdown of covered costs depending on length of stay:
- Days 1 through 20: Part A pays the entire cost of any covered services.
- Days 21 through 100: Part A pays for all covered services, but you’re now responsible for a daily coinsurance payment. For 2020, this is $176 per day.
- After 100 days: Part A pays nothing. You’re responsible for the entire cost of SNF services.
Medicare Part C (Medicare Advantage) and Medicare Supplement (Medigap) plans may cover some of the costs not covered by Part A. When you’re deciding what type of Medicare plans to enroll in, it’s important to consider these plans as well.
In-home care involves any healthcare services that you receive in your home, instead of going to a hospital or doctor’s office. Typically, these in-home care services are coordinated with a home health care agency. Both Medicare parts A and B can cover this type of care.
Examples of services provided during in-home care include:
- part-time skilled nursing care or hands-on care
- physical therapy
- occupational therapy
- speech-language therapy
- injectable osteoporosis drugs for women
Medicare only covers medically necessary services. Custodial care, meal preparation, and cleaning aren’t covered.
If you have original Medicare, you won’t pay anything for covered in-home healthcare services. They’ll also pay 20 percent of the cost for any necessary durable medical equipment (DME). Examples of DME include wheelchairs, walkers, or hospital beds.
Hospice care is a special type of care that someone receives when they’re terminally ill. Hospice focuses on managing symptoms and providing support.
Examples of services provided during hospice care include:
- care from doctors and nurses, including exams and visits
- medications or short-term inpatient care to manage symptoms and ease pain
- medical devices or supplies such as wheelchairs, walkers, or bandages
- physical and occupational therapy
- short-term respite care, which involves care at a nursing home or hospital during times when your caregiver is not available
- grief counseling for your family and loved ones
Medicare Part A generally covers all costs of hospice care, with the possible exception of small copays for respite care or prescriptions. Medicare also doesn’t pay for room and board while you’re receiving hospice care.
In addition, there are some expenses that Medicare will no longer cover after hospice benefits start. These include any medication or treatment intended to cure a terminal illness. It’s important to coordinate a plan with a hospice care team to make sure everything is organized and covered.
- Be 65 years or older. You can enroll beginning 3 months before your 65th birthday.
- Have a disability. You can enroll beginning 3 months before you reach the 25th month of receiving disability benefits.
- Have end stage renal disease. Enrollment times can depend on your individual situation.
Once you have enrolled in original Medicare, you’re eligible to receive coverage for long-term care.
Am I eligible for a skilled nursing facility?
To qualify for coverage to stay at an SNF, you must first have a qualifying hospital stay: your stay must last at least 3 consecutive days and be classified as “inpatient.”
In addition, your doctor must document that you need daily inpatient care or supervision that can only be given at an SNF. You’ll typically need to enter the SNF within 30 days of leaving the hospital.
Am I eligible for in-home care?
If you have original Medicare, you qualify for in-home care if your doctor classifies you as “homebound.” This means that you have trouble leaving home without assistive equipment (such as a wheelchair) or the help of another person.
Your doctor must also certify that you need skilled medical services that can be provided at home. Examples include part-time skilled nursing care, physical therapy, or occupational therapy. Your doctor will create a plan of care for you.
Am I eligible for hospice care?
To be eligible for hospice care coverage, you must:
- Be certified as terminally ill. This typically means that you have an estimated lifespan of less than 6 months, although your doctor can extend this if necessary.
- Choose to accept palliative care instead of treatment to cure your condition. Palliative care is focused on providing comfort and support.
- Sign a statement indicating that you’ve chosen hospice care for your condition instead of other Medicare-covered treatments.
Although Medicare covers some services of long-term care, there are many others that it doesn’t cover.
For example, Medicare doesn’t cover custodial care, which entails assistance with daily living activities like eating, dressing, and using the toilet. It’s a big component of the care that’s provided in nursing homes or assisted living facilities.
For additional help with long-term care that isn’t covered by Medicare, consider the following options:
- Medicare Advantage. Private insurance companies offer these plans. Some Advantage plans may offer more long-term care benefits than original Medicare.
- Medigap. Like Advantage plans, private insurance companies sell these policies. Medigap plans can help with coinsurance and copayments costs associated with long-term care.
- Medicaid. Medicaid is a joint federal and state program that supplies healthcare for free or at a low cost. The available programs and requirements for income eligibility can vary by state. Find out more through the Medicaid site.
- Long-term care insurance. Some insurance companies sell a type of policy called “long-term care insurance”. These policies are meant to cover long-term care, including custodial care.
- Program of All-inclusive Care for the Elderly (PACE). PACE is a program that’s available in some states to help cover costs associated with medical or long-term care provided at home. Visit the PACE site to learn more.
- Department of Veterans Affairs (VA). The VA may help provide long-term care for some veterans. To learn more about potential benefits, contact your local VA health center or visit the VA site.
- Out of pocket. If you choose to pay out of pocket, that means you’ll be paying for all the costs of long-term care on your own.
Medicare covers some types of long-term care including in-home care, hospice care, and short stays at skilled nursing facilities. To be eligible for coverage, you must meet certain rules.
There are some aspects of long-term care that aren’t covered by Medicare. These include nonmedical services that are commonly provided at nursing homes and assisted living facilities, such as custodial care and room and board.
There are several additional ways to get assistance for the costs of long-term care. Some of these include enrolling in an Advantage or Medigap plan, using Medicaid, or buying a long-term care insurance policy.