Medicare’s Long-Term Care Benefits – They May Not Cover Nearly as Much as You Might Think

Long Term Care Medicare

Medicare doesn't cover Long Term Care. Plan accordingly.

No one wants to end up in a nursing home.  No one wants to put someone in a nursing home.  But most people are not aware that Original Medicare – which consists of Medicare Part A and Part B – doesn’t include long term care benefits.  It’s is a primary health care coverage program. Though Medicare pays for a long list of hospital and doctors’ services, there is a great deal of misconception regarding what actually is and isn’t covered. Because Medicare is primarily a senior-related program, there are many people who believe that it provides full coverage for nursing facility and home health care services. This, however, is not the case at all.

For instance, even if an individual qualifies for Medicare Part A skilled nursing facility benefits, very little is actually covered. And, depending on how long an individual remains in a long-term care facility, there could be an out-of-pocket cost that is in excess of $13,000. ($167.50 per day X 80 days = $13,400).

Medicare Part A Skilled Nursing Facility Coverage

If you stay multiple days in a facility (per benefit period) you’ll pay

  1. Days 1 through 20 $0
  2. 21 through 100 $167.50 per day (in 2018)
  3. Days 101 and beyond – All costs

In addition, not all Medicare enrollees will qualify for the program’s skilled nursing facility coverage. As an example, if the only type of care you need is considered to be “custodial” in nature – meaning that you just simply require assistance with basic daily activities like bathing and dressing – Medicare will not pay.

Other qualification factors include:

  • Having a qualifying hospital stay just prior to entering the facility (typically, this requires that you spend at least three nights in the hospital before going to the facility)
  • The nursing home facility is entered for a health condition that is a “hospital-related” condition (in this case, the condition would need to be something that you can essentially recuperate from, as versus an on-going chronic situation such as Alzheimer’s disease)

Medicare and Home Health Care

Although Medicare may pay for some home health care services, these too can be limited – and there are some strict requirements that must first be met. For example, your doctor must certify that you need a skilled type of care (as versus custodial).

In lieu of that, you may also qualify for Medicare’s home health care benefits if you require physical, speech, and / or continued occupation therapy services, or if you are homebound due to your health condition (and your doctor certifies that this is so).

Here, too, there will likely be some out-of-pocket expenses to be mindful of. As an example, while you might not have to pay anything for the actual home health care services that you receive, if you need durable medical equipment such as a walker, wheelchair, and / or other item, you will typically be required to pay for 20% of the Medicare-approved amount.

Because qualifying for Medicare’s long-term care benefits cam be somewhat tricky, it is important to have a good understanding of what is – and what is not – covered, as well as the amount that you could be required to pay over and above Medicare’s coverage.

Got a Medicare question? We love questions. Contact us.
Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.