Medicare was established in the mid-twentieth century to help aging Americans. It provides health insurance for millions of Americans aged 65 and older, certain people under age 65 with disabilities, and people with End-Stage Renal disease.
Knowing this, you might expect or assume Medicare assists with long-term care expenses. However, Original Medicare generally does not cover long-term care or nursing home care.
Still, it is important you know what Medicare does and does not cover, so you or a loved one can be prepared in times of need.
Long-Term Care, or “Custodial Care”
First, let’s talk about what long-term care actually is.
It is not medical hospital care. Long-term care means help is needed with activities of daily living, which can be thought of as everyday life tasks. 1
Examples of everyday life tasks include:
- Using the restroom
- Mobility (which can involve walking and moving around, or transferring from bed to chair)
While Original Medicare does not pay for long-term care or nursing home care, it continues to pay for covered services such as hospital care and doctor services as needed.
Medicare is mainly focused on paying for hospital care, doctor services, as needed.
Medicare pays for short-term skilled nursing care services following hospitalization.
Medicare will help pay for a short stay in a skilled nursing facility if you meet all of the following conditions:
- Hospital admission with inpatient stay of at least three days
- Admitted to a Medicare-certified nursing facility within 30 days
- You need skilled care
If you meet all of those conditions, Original Medicare will pay a portion of the costs for up to 100 days:
- First 20 days, 100 percent
- Days 21-100, daily copayment
- Days 101+, Medicare does not pay
Medicare Advantage plans must cover the same services as Original Medicare and may also pay for some long-term and chronic care services. Depending on your plan, Medicare Advantage Plan may cover nursing home care. Be sure and ask specifics about long-term care services.
Long-term care provided by Medicaid
Medicaid is a state and federally funded program to help people on limited incomes or below poverty levels. Program eligibility varies state-to-state, and most often it depends on the applicant’s income and personal assets. If you are eligible for Medicaid, it may cover long-term care in a nursing facility in your area and state. Around six out of ten nursing facilities take Medicaid.2
Some states have a Program for All-inclusive Care for the Elderly, or PACE.3 PACE is for qualifying individuals who require the level of care provided in a nursing facility or in a community.
The program has a provider team who coordinates and assesses the enrollee’s needs. PACE also provides all services determined by a health professional team as necessary to improve and maintain the enrollee’s health. PACE is tied to the community where the program serves enrollees. This means an enrollee must be in the geographic area of the PACE location.
Remember that even though Original Medicare doesn’t cover your nursing home care, you’ll still need Medicare for hospital care, doctor services, and medical supplies while you’re in a nursing home.
Other Ways You Can Pay for Nursing Home Care:
- Personal resources
- Long-term care insurance
Medicare does not pay for most long-term care services except in the limited and specific cases described above. Knowing this can help you better prepare for your future and research alternative methods of paying for long-term care.