What Does Medicare Consider Long-Term Care
Long-term care is a phrase that encompasses both medical and custodial care for disabilities and chronic conditions. Long-term care can be provided in a wide range of locations such as at home or in a facility. Care includes assistance as simple as meal delivery or as robust as occupational therapy.
Basic Activities of Daily Living
When a person needs assistance with daily living activities, better known as ADLs, Activities of Daily Living, long term care may be the solution.
- Dressing and grooming
- Transferring, being able to move from one body position to another
- Walking, technically referred to as ambulating
- Memory care & stimulation
Does Medicare Pay for Long-Term Care
No, Medicare does not pay for long-term care if it is the only care you need. When the only care necessary is custodial care, or help with daily activities, Original Medicare will not pay. The cost falls to the Medicare beneficiary.
Many beneficiaries with a need for long-term care have a chronic illness or disability. This drives the need for long-term care. In these instances, your Original Medicare will pay for rehabilitative care and skilled services.
If you spend 3 consecutive days as an inpatient in a hospital and are sent to a skilled nursing facility or nursing home for observation, Medicare will provide coverage. Services would include items such as room, meals, and therapy or nursing care. If you are sent to another type of facility, other rules would apply.
How Long Does Medicare Pay for Nursing Home or Skilled Nursing Facility
Benefits would be covered by Medicare at 100% for days 1-20. Starting with day 21, the beneficiary would have a daily copayment, until day 100. After 100 days, Medicare no longer provides any benefits for ongoing care at a nursing home or skilled nursing facility.
If the need for nursing care still exists after day 100, you will be responsible for the full cost until your resources have been exhausted. At that point, you can apply for Medicaid.
Thankfully, the average stay in a nursing home is just 22 days. It would be prudent to discuss your concerns and expectations with your doctor or health care team. Everyone needs to be on the same page if you are trying to complete your therapy and get home before the end of day 20 when your cost-share increases.
Will Medicare Pay for In-Home Care
Absolutely. Medicare wants to keep expenses as low as possible and if you can get the necessary treatment at home, then Medicare will pay according to the policy.
You would be eligible for in-home care if you are under the care of a doctor, and one or more of the following applies:
- You are homebound
- Require occasional skilled nursing care
- Require services such as physical, language or occupational therapy. The therapy must be reasonable, and the condition is expected to improve
All services must be provided by a Medicare-approved Home Health Agency. Typically, the home health agency coordinates all services that your medical provider orders.
With Medicare, you pay zero for home health services and 20% of the Medicare-approved amount for durable medical equipment (DME).
Will Medicare Pay for Care Received in an Assisted Living Facility
No. An assisted living facility provides services referred to as custodial care, such as bathing assistance, medication management, meals, and transportation. Medicare does not provide coverage for services received at an assisted living facility.
Although, at some point, most of us will require care that exceeds that which our family can provide. When full-time help is needed, the national institute on aging can help you and your family choose the care that will best meet your needs.
Does Medicare Pay for Acute Care
Yes, beneficiaries that suffer from an acute, or short-term sudden illness or injury are covered.
Services can be provided in a hospital, urgent care center, nursing home or skilled nursing center.
Surgical needs, the emergency room, and intravenous fluids all fall under the acute care umbrella.
As do, evaluation by your healthcare provider, the intensive care unit and ambulance.
The need for follow up acute care can stem from a recent hospitalization due to an injury or a medical condition that is urgent in nature.
Acute care is defined as care that lasts no more than 12 weeks.
Does Medicare Pay for Long-Term Memory Care
Medicare does pay for memory care if it is received in a covered facility. Care for Alzheimer’s or memory impairment is covered when the beneficiary receives services at a nursing home or skilled nursing facility.
Most nursing homes have a special “memory care unit” that specializes in treating patients with a progressive cognitive disorder. Memory care units provide specialized care that requires additional training and offer a lower patient to staff ratio.
The cost of these specialized services tends to be higher than most other nursing services required by beneficiaries.
The cost of treatment increases as the disease progresses, causing beneficiaries to need more specialized care. An assisted living facility, which is not covered by Medicare, runs about $60,000 a year for memory care.
How to Pay for Long Term Care
Long term care is the most utilized care and it’s also the coverage for which most people have not planned. Meaning that at some point, most people will need the services provided in long term care facility.
However, few people have actually purchased a separate insurance policy to provide coverage for the services available in a long-term care facility. Most beneficiaries are paying for long term care through Medicare, Medicaid, Veteran’s benefits and personal funds.
Since Congress passed the Older Americans Act (OAA) in 1965, the social services group drives the programs to provide community service to low-income Americans.
The OAA brought about the Administration on Aging, whose objective is to protect the rights of beneficiaries and strengthen long term care programs available throughout the country.
There are a lot of choices, you are encouraged to get help reviewing your options by contacting an eldercare lawyer, a geriatric care manager and/ or taking advantage of any veteran’s benefits if relevant.