Medicare does not cover long-term care, but in some particular circumstances, coverage may be available.
Medicare does not cover long-term care if that is the only type of care a person requires. In many cases, when an individual needs long-term care, they are responsible for 100% of the costs.
Continue reading to learn when Medicare covers long-term care.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Long-term care involves a broad range of services, including support for personal care for an extended period.
Long-term care differs from acute care. Acute care services involve medical care for the short term.
Usually, most long-term care services do not involve medical care. Instead, services may include assistance or support that is necessary because a person might not be able to do the essential activities of daily life, such as grooming, dressing, and eating.
An individual may need long-term care due to a variety of circumstances, such as a chronic illness, accident, or advanced aging.
According to the Department of Health and Human Services, about 70% of adults who live to the age of 65 will require long-term care services sometime before the end of their life.
People can receive long-term care from:
- nursing homes
- assisted living facilities
- home care visits
An inpatient stay in various types of medical facilities might include both medical and custodial care.
For example, in some cases, long-term care in a skilled nursing facility may involve certain types of medical and custodial care.
However, there are several differences between the two types of care.
A licensed or skilled medical professional will provide medical care. Examples include:
- wound care
- administration of injections
- physical and occupational therapy
- pain management
- catheter care
Custodial care helps meet the personal and health needs of an individual, including many activities of daily living. It involves nonmedical care, which a nonlicensed caregiver often provides.
Custodial care may involve helping a person with the following:
- transferring out of bed
Custodial care may also include home services, such as laundry and housekeeping.
In some situations, an individual receives both medical and custodial care as part of long-term care services, but most long-term care includes only custodial care.
Where custodial care occurs alongside medical care for an acute illness or injury, Medicare Part A covers long-term care. Most Medicare-approved long-term care occurs in a skilled nursing facility.
Medicare Part A coverage in a skilled nursing facility includes the following:
Hospice care helps someone who is terminally ill.
Hospice services may include medical care, such as giving medication, caring for a wound, and catheter care. It may also include the help of a hospice aide and social worker.
Medicare Part A covers long-term care, including custodial care, under hospice services when certain conditions are met. A doctor must certify that the individual has a life expectancy of 6 months or less.
A patient must also accept comfort care instead of care to cure their illness. Comfort care involves palliative care to improve a person’s quality of life and manage symptoms.
A person does not pay anything for hospice services. Medicare Part A covers the costs in full.
Usually, original Medicare does not cover long-term care, but there are a few exceptions and special considerations.
Medicare Part A, which is hospital insurance, pays for long-term care services, including custodial care, when a person also requires medically necessary skilled nursing or rehabilitation care.
For example, Medicare covers limited long-term care only if it is for recovery from an injury or illness and not due to a chronic or long-term condition.
An individual must also have a minimum 3-day hospital stay immediately before requiring long-term care.
The patient must also receive the physician-ordered medical care from therapy staff or skilled nursing staff. Medicare-approved skilled nursing facilities or a home health agency must provide the care.
Typically, Medicare does not pay for long-term care services.
Most long-term care involves custodial care. Medical care and custodial care differ.
Custodial care includes help with daily living activities, such as eating, dressing, and bathing, and when custodial care is the only care necessary, Medicare does not cover it.
There are exceptions to Medicare’s coverage of long-term care.
Medicare Part A covers long-term care for a limited amount of time when an individual requires medical attention and custodial care.
In this situation, Medicare limits long-term coverage to 100 days, and a person may have to pay a copayment.
Medicare covers the full cost of custodial care when a person receives care from a hospice.