Life expectancy continues to grow over the years. In America, the average life expectancy is 79 years. Because of this, people turning 65 in today’s society have a 70% chance of eventually requiring some kind of long-term care support.
A semi-private room at a nursing home averages to $82,125 a year. So, you could see how having coverage for long-term care could be beneficial.
However, many long-term care patients are surprised by the fact that their Medicare coverage doesn’t pay for everything they thought it would. Knowing the relationship between Medicare and long-term care can better prepare you for your financial future.
How is Long-Term Care Different from Skilled Nursing Facility Care?
Medicare only covers medically necessary care that is designed to help you recover and get back to living independently. So Medicare covers skilled nursing facility (SNF) care because it is typically considered medically necessary by your doctor and is usually short term.
Once you have had the status of “inpatient” for at least 3 days at the hospital, your doctor can have you transferred to an SNF to finish your healing there. Your doctor must believe that your condition will improve in an adequate amount of time in order to have you placed in an SNF.
Some reasons someone might need care at an SNF are for recovery after an injury, serious illness or intense surgery. SNF stays are also common after a stroke.
How Medicare Covers Skilled Nursing
If your stay at a skilled nursing facility is deemed medically necessary, your Original Medicare benefits will help to pay for your care.
If your stay is 20 days or less, Medicare will cover all of the cost. If your stay lasts between 21 and 100 days, you will be responsible for $167.50 each day beginning on the 21sst day. If your stay exceeds 100 days, you’re required to pay all costs from that point on.
Remember, your coverage for a skilled nursing facility is not a one and done type thing. Your benefit builds back up once you have been out of the facility (and hospital) for at least 60 days in a row. Then a new benefit period begins.
As you can see, a stay in an SNF can get quite expensive. Having a Medigap plan could benefit you immensely. Medigap plans help you pay for some things that Original Medicare leaves for you to pay, such as your daily copays at a skilled nursing facility.
Long-Term Care
Unlike SNF care, long-term care is needed for an extended period and the patient may not be expected to return to caring for himself. If long-term care is the only form of care you need, Medicare will not cover it.
If you are someone who only needs help with activities of daily living (ADL), you would be considered a long-term care patient. A few examples of ADL are dressing, eating, transitioning, bathing, and using the toilet.
If you find that your only option is being admitted to a long-term care facility such as a nursing home, you can expect to pay for that care yourself. Many individuals plan ahead for this possible situation and purchase long-term care insurance to pay for their expected future expenses related to long-term care. Policies are very flexible today and will often cover assisted-living facilities, nursing homes and/or the cost of a caregiver in your own home. It is wise to look into this type of insurance when you are still healthy enough to qualify.
People with low incomes can also apply for Medicaid to help pay for their stay in the LTC facility.
Home Health Care Services
Long-term care, also called custodial care, can be provided in places other than nursing homes. In fact, most custodial care patients prefer to receive their care at home. If you are fortunate enough to have a family member or friend to help you, you could save a lot of money.
However, if you receive custodial care at home from a paid caregiver, Medicare won’t cover that either. With that being said, if your doctor determines that you must receive medically necessary care at home, Medicare may cover this type of home health service.
This home health care that Medicare is willing to cover is similar to the care provided by an SNF. In order for the service to be covered, it must be short-term care meant to help you recover in an adequate amount of time.
Medicare usually pays for up to 28 hours a week for your home health care. Some home health care services you might receive are nursing care, physical therapy, and custodial care. If custodial care is not the primary reason for the home health aide, Medicare will usually cover the full service.
You Still Need Medicare as a Long-Term Care Patient
Even though Medicare doesn’t pay for long-term care, you still need to have Medicare for other reasons.
You’ll need Part A for coverage if you have to go to the hospital or a skilled nursing facility. Part B is very important as well. You’ll need Part B for your routine doctor visits, durable medical supplies, and lab tests.
If you need long-term care, you probably need prescriptions as well. You’ll need Medicare Part D as well to help pay for those prescriptions. When choosing a Part D plan, you should always check with your nursing home to see which drug plans their pharmacy works with.
Hospice
Long-term care while in hospice is covered by Medicare Part A. You can qualify for hospice if you are terminally ill and have 6 or fewer months to live. Medicare requires you to receive hospice care at a certified hospice facility.
Your Medicare might even pay for a certified home health aide while you are in hospice.