Will Medicare Cover My Long-Term Care Expenses?

Will Medicare cover my long-term care expenses?

The short answer is, not really!  At least not all of the traditional long-term care expenses anyway. Local long-term care expert, Brad Fox of Medical Claims Rx recently updated us on the status of Medicare payments around long-term care.   Some of the numbers may surprise you.

Medicare doesn’t really cover long-term care as LTC is commonly defined, that is, care that lasts over a period of greater than 90 days.  What Medicare does cover is short-term recovery, generally following an acute episode such as a stroke.  Specifically, Medicare covers care in a Medicare approved skilled nursing facility (SNF) for up to 100 days in a benefit period, if the care is preceded by an inpatient hospital stay of at least 3 days and if the patient is admitted to the SNF within 30 days of the hospital stay.  Medicare will pay for the first 20 days in full; for days 21-100 there is a co-pay amount, which this year is $141.50/day. 

Medicare only pays for the skilled nursing home care as long as the person is getting what Medicare deems to be skilled level care and generally they also want the patient to show improvement.  On average, Medicare pays for 30-35 days of care in a skilled nursing facility.  It is very rare for Medicare to pay for the full 100 days of benefits.

Since there are many types of facilities out there it is important to remember that Medicare does not pay for assisted living or skilled care in a non-Medicare facility.  However, Medicare does pay for some skilled care in one’s home if it follows an acute episode.  Medicare may also include some limited non-skilled services from a home health aid if it is in conjunction with other skilled services.  Typically, the home health aid’s services are only for 1-4 hours a week to do bathing or some other personal care, and they come only when they can fit you in.  These Medicare covered skilled home care services will also generally end when the person stops showing improvement and will only last for a matter of weeks not months.

Lastly, if one has a Medigap plan it typically pays as long as Medicare pays and stops when Medicare stops.  If one has a group health plan, it generally follows the same guidelines as Medicare, though a few plans may pay even if Medicare does not (e.g. the NC state health plan pays at Carolina Meadows, a non-Medicare facility).

This can all be very confusing and potentially costly, so please ask us if you have any questions.  Medicare open enrollment is still a few months off, but these are things to be thinking about now.

About Jim Miller

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