The Core Difference: Skilled vs. Custodial Care
The fundamental reason TRICARE does not cover long-term nursing home stays is the distinction between two types of care: skilled and custodial. Nursing homes primarily provide custodial care, while TRICARE's benefit is limited to medically necessary skilled care. Understanding this difference is key to navigating your coverage.
What is Skilled Nursing Care?
Skilled nursing care involves medical services that can only be performed by a licensed nurse or therapist. This is typically a short-term, rehabilitative benefit following a serious illness, injury, or surgery. TRICARE will cover skilled nursing facility (SNF) care, but only if specific criteria are met.
- Required prior hospital stay: Beneficiaries generally must have a qualifying hospital stay of at least three consecutive days.
- Timely admission: Admission to the SNF is usually required within 30 days of the hospital discharge.
- Rehabilitative focus: The goal of the care must be rehabilitation and recovery, not ongoing maintenance.
What is Custodial (Long-Term) Care?
Custodial care, also known as long-term care, involves non-medical assistance with daily activities. This is the type of care commonly associated with nursing homes. It focuses on maintaining a person's current physical or mental condition rather than improving it. Services include:
- Help with bathing and dressing
- Assistance with eating and personal hygiene
- Support with mobility and transfers
- Supervision for cognitive impairment
TRICARE For Life and Long-Term Care
For beneficiaries over 65 who are eligible for both Medicare and TRICARE For Life (TFL), the rules surrounding nursing home care are a bit more complex, but the outcome for custodial care is the same. Under TFL, Medicare is the primary payer and TRICARE acts as a secondary payer. Neither program covers long-term, custodial nursing home care.
For short-term, medically necessary skilled nursing care, the coverage works in tandem. Medicare will pay for the first 20 days of a qualified stay at 100%. For days 21 through 100, Medicare requires a copayment, which is covered by TRICARE For Life. After day 100, if the care is still considered medically necessary skilled care, TRICARE becomes the primary payer, and the beneficiary is responsible for their cost-share. However, this is for skilled care only, and once a patient's needs shift to primarily custodial, coverage ends for both Medicare and TRICARE.
Comparison: TRICARE Coverage for Different Care Types
| Type of Care | TRICARE Coverage | Details & Limitations |
|---|---|---|
| Long-Term/Custodial Care | No | Excludes assistance with daily living activities provided in nursing homes or assisted living facilities. |
| Skilled Nursing Facility (SNF) Care | Yes | Short-term, rehabilitative care following a qualifying hospital stay. TFL beneficiaries may have combined Medicare/TRICARE coverage. |
| Home Health Care | Yes | Medically necessary skilled nursing and therapy services for homebound beneficiaries. Requires pre-authorization. |
| Hospice Care | Yes | Coverage for terminally ill patients with a life expectancy of 6 months or less, focusing on comfort rather than cure. |
| Assisted Living Facility Care | No | Excluded, as it is considered custodial care. TRICARE does not cover routine personal care in these settings. |
| Durable Medical Equipment (DME) | Yes | Medically necessary equipment like wheelchairs and hospital beds is covered when prescribed by a doctor. |
What Are Your Options for Long-Term Care?
Since TRICARE and Medicare do not cover custodial nursing home care, beneficiaries must seek alternative funding options. Planning ahead is crucial.
- Long-Term Care Insurance: For those who plan ahead, purchasing a separate long-term care insurance policy from a commercial provider can cover the costs of nursing homes and assisted living. It is important to note that the Federal Long Term Care Insurance Program (FLTCIP) has suspended new enrollments.
- Veterans Affairs (VA) Benefits: Veterans with service-related disabilities or specific financial needs may be eligible for long-term care services through the Department of Veterans Affairs. VA benefits may cover nursing home care, home health care, and other support services for eligible veterans. Benefits and eligibility vary, so contacting the VA is the best course of action.
- Medicaid: This is a state and federal program that may cover long-term care costs for individuals with limited income and assets. Eligibility requirements are strict and vary by state. This is often an option considered when other resources have been exhausted.
- Private Pay: Beneficiaries can use their own savings and retirement funds to pay for long-term care out-of-pocket.
- Special Programs (ECHO): For TRICARE beneficiaries with special needs, the Extended Care Health Option (ECHO) offers additional financial assistance for a limited range of services that may be provided in a non-institutional setting. However, this is not a substitute for comprehensive nursing home coverage.
Conclusion
In summary, TRICARE insurance does not cover nursing home care that is long-term or custodial in nature. The only coverage available in a nursing home setting is for short-term, medically necessary skilled nursing care, usually following a hospital stay. This critical distinction is important for military families, veterans, and all TRICARE beneficiaries to understand when planning for potential future care needs. A combination of personal savings, long-term care insurance, or specific VA benefits may be necessary to cover the high costs of ongoing nursing home care.
For more information on benefits and specific coverage details, it is always recommended to consult your TRICARE regional contractor or the official TRICARE website.
Additional Resources
The Crucial Difference: What TRICARE Covers vs. What It Doesn't
| Feature | Skilled Nursing Facility (Covered) | Nursing Home (Not Covered) |
|---|---|---|
| Primary Purpose | Rehabilitation after an illness, injury, or surgery. | Long-term residential and custodial care. |
| Medical Need | Medically necessary care ordered by a doctor. | Assistance with activities of daily living (ADLs). |
| Typical Duration | Short-term stay, with a focus on recovery. | Long-term or indefinite stay. |
| Associated Condition | Acute medical conditions, post-operative recovery, and intensive therapies. | Chronic illness, cognitive disorders, or general aging needs. |
| Facility Certification | Medicare-certified Skilled Nursing Facility. | Standard nursing home or assisted living facility. |
| Prior Requirement | Requires a qualifying hospital stay of at least 3 days. | No prior hospital stay required for admission. |
FAQs About TRICARE and Nursing Home Coverage
Q: Does TRICARE cover long-term care in a nursing home? A: No, TRICARE does not cover long-term custodial care, which is the type of care typically provided in a nursing home. Long-term care is considered a non-covered benefit.
Q: What is the difference between skilled nursing care and nursing home care? A: Skilled nursing care is medically necessary, short-term care for rehabilitation, usually following a hospital stay. Nursing home care is typically long-term, custodial care that assists with daily activities and is not medically rehabilitative. TRICARE may cover skilled nursing but not custodial care.
Q: How does TRICARE For Life (TFL) work with nursing home care? A: Under TRICARE For Life, Medicare is the primary payer and TRICARE is the secondary. Neither program covers long-term custodial care. For short-term skilled nursing care, TFL will cover the Medicare copayment, and then becomes the primary payer after Medicare benefits are exhausted, as long as the care remains medically necessary and skilled.
Q: Can I use TRICARE for assisted living facilities? A: No, TRICARE does not cover assisted living facility care or any routine personal care associated with it. Assisted living is also categorized as custodial or long-term care.
Q: What are my options if I need long-term nursing home care? A: Since TRICARE does not cover it, you must explore other options. These include using personal savings, purchasing private long-term care insurance, applying for Veterans Affairs (VA) benefits for eligible veterans, or seeking eligibility through Medicaid if you have limited income and assets.
Q: Does TRICARE ever cover custodial care? A: Generally, no. Custodial care is excluded from TRICARE coverage. However, in rare cases, TRICARE may cover some custodial care if it is provided in conjunction with authorized and medically necessary home health services for a seriously ill or injured service member.
Q: Is there any TRICARE program that helps with long-term care? A: While TRICARE does not cover institutional long-term care, some beneficiaries with special needs may be eligible for the Extended Care Health Option (ECHO). This program provides financial assistance for additional services beyond the basic TRICARE benefit, which may include home health services, but it is not a solution for long-term nursing home costs.
