When does Medicare cover Long term care?


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Many Medicare beneficiaries only plan for paying for long term care is Medicare. They are shocked when they find out Medicare does not cover long term care.

Of course, Medicare does cover medical services in long term care settings, such as doctors visits and such, but it is not going to pay for the custodial care that is the bulk of most people’s long term care needs.

Unlike medically-necessary care, “custodial care” helps with the six activities of daily living. There are six activities of daily living: Transferring, Dressing, Bathing, Eating, Toileting, and Continence.

The cost of care to help a patient with activities of daily living must be paid out of pocket, through private insurance policies designed for these specific expenses, or by qualifying for a government program like Medicaid.

That being said, there is a very limited amount of long term care services that Medicare does cover in specific situations. We will go over those below.

Long Term Care: What Medicare Covers

There is a very limited amount of long term care services that Medicare does cover in specific situations.

Medicare coverage for Assisted Living Facilities

Assisted living facilities allow residents to live independently while having access to 24-hour care and assistance.

For many people, moving into an assisted living facility is their preferred choice, as these facilities provide not only social and community involvement, but also allow you to not have to deal with the responsibilities of upkeeping a home.

The average cost of an assisted living facility was $4,051 monthly in 2019.

Medicare provides no coverage for assisted living facilities. 

Medicare coverage for Continuing Care Retirement Communities (CCRC)

Continuing Care Retirement Communities, or CCRCs, are retirement communities that allow residents to age in place.

They include accommodations for independent living, assisted living, and nursing home care.  You must move in when you are healthy and can be in the independent living section of the CCRC.

They are ideal for people who want to age in one place without sacrificing quality of care or freedom.

Almost all CCRCs are going to include common dining areas, activities, and social events. Most also offer homemaker services, such as transportation, housekeeping, and laundry, though this will vary by location.

Medicare does not cover CCRCs.

Due to the unique payment structure, it is not really possible to purchase long term care insurance to cover these services.

Medicare coverage for Adult Day Care

Adult day care facilities can greatly help family members who choose to take care of an aging relative.

Usually open during work hours, these facilities give caregivers a place to take their loved one and know they are safe.

The caregiver is able to live their life, keep going to their job, and get a break from the taxing work that can be caring for an elderly loved one.

Adult day care facilities also offer social interaction to the patients. Some of these facilities even specialize in Alzheimer’s care.

The average cost of adult day care was $70 daily in 2019.

Medicare does not pay for adult day care services. 

Recently, some Medicare Advantage (Part C) plans have introduced benefits to partially cover these services. Not every Part C is going to include this though, and a Part C plan should not only be purchased for this coverage.

There are some long term care insurance policies that will pay out for adult day care.

Medicare coverage for Home health care

Home health care allows for you to not only start your care at home, but you can also end care at home. If you want to maintain the highest level of independence while getting the medical care you need, home health care might be for you.

The average cost of professional home health care was $4,385 monthly in 2019.

Medicare will cover skilled nursing care in the home for a limited time period, but not custodial care. Care must be prescribed by a doctor and needed part-time only.

The senior must be “confined”, or homebound, meaning they are unable to leave the home without the assistance of another person.

For most people who end up aging at home, they are mainly going to need custodial care services. Medicare will not pay for this. 

There are many long term care insurance policies that cover home health care services. There are also options for pre-paying home health care hours that have much easier health qualifications.

Medicare coverage for Skilled Nursing Facilities (& Nursing Homes) 

Many skilled nursing facilities and nursing homes actually operate as both, having a separate floor or section of the facility for each. The difference between these two comes down to the care provided.

A skilled nursing facility is going to provide care that is medically-necessary. They are staffed with trained medical professionals, such as licensed nurses, physical and occupational therapists, speech pathologists, and audiologists.

For a skilled nursing facility, Medicare will pay for 100% of the cost of care up to 20 days. Medicare covers approximately 80% of the cost for up to 80 more days.

The care must be for recovery following an inpatient hospital stay of 3 days and the reason for being in the skilled nursing facility must be related to the hospital stay.

A doctor must certify that you need this care for Medicare to cover it.

On day 101, Medicare will not cover anything. 

Nursing homes are going to mainly provide custodial care. The average cost of a nursing home was $8,517 monthly in 2019

For nursing home care, Medicare provides no coverage. 

There are many insurance policies you can buy that will cover the cost of a nursing home.

Medicare coverage for Hospice

Medicare provides coverage for hospice for people whose doctors have determined to have less than 6 months to live.

This is the only place Medicare is going to cover custodial care.

As you can see, while you have many options for receiving long term care services, all of the options have little, if no, Medicare coverage except for hospice care.

Coming up with a plan for long term care, how you want to receive your care and how you are going to pay for it, is key in making sure you are able to age how you want.

Cardinal can help you look at your situation and your wants, come up with a plan, and give you the tools and products to make sure this plan happens.

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