What types of services and care will Medicare provide for long term services?

Over 60% of individuals aged 65 and older will require some form of long-term care in their lifetime, but many are surprised to learn that Original Medicare provides very limited coverage. It is crucial to understand what types of services and care will Medicare provide for long term services and what you may need to cover with alternative solutions.

Quick Summary

Medicare offers limited, short-term coverage for skilled nursing facility stays, home health services, and hospice care under specific conditions, but it generally does not cover long-term or custodial care for daily living activities. Expanded coverage options may be available through certain Medicare Advantage plans.

Key Points

• Medicare covers skilled care, not custodial care: Original Medicare provides limited, short-term coverage for skilled medical services needed for recovery from an illness or injury, but it does not cover long-term personal or custodial care for daily living activities.

• Skilled nursing facility stays are time-limited: Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period, which must follow a qualifying three-day inpatient hospital stay.

• Home health care is for homebound individuals: Coverage is provided for intermittent, medically necessary skilled care at home for individuals who are certified as homebound by a doctor.

• Medicare Advantage plans may offer expanded benefits: Some private Medicare Advantage plans offer supplemental benefits that can help with non-medical long-term care services, unlike Original Medicare.

• Alternatives like Medicaid and private insurance are necessary: For extensive long-term care, individuals often need to rely on Medicaid (if they qualify), purchase private long-term care insurance, or use personal savings to cover costs.

The critical distinction between skilled and custodial care

To understand what Medicare covers, it is essential to distinguish between two primary types of care: skilled and custodial. Skilled care involves services that can only be performed safely and effectively by or under the supervision of skilled medical professionals, such as registered nurses or physical therapists. This type of care is often short-term, with the goal of helping a person recover from a specific illness or injury. Custodial care, in contrast, involves non-medical assistance with routine daily tasks, also known as Activities of Daily Living (ADLs). This includes help with bathing, dressing, eating, and using the bathroom. Medicare explicitly states that it does not cover long-term or custodial care if it is the only care a person needs.

Medicare's limited coverage for long-term services

While Original Medicare (Parts A and B) does not cover long-term custodial care, it does provide coverage for certain medically necessary services that may be part of a longer-term care plan. This coverage is often conditional and temporary, focusing on recovery and rehabilitation rather than ongoing maintenance.

Skilled Nursing Facility (SNF) care

Medicare Part A provides coverage for short-term stays in a skilled nursing facility, but only under specific circumstances.

• Qualifying stay: The stay must follow a qualifying inpatient hospital stay of at least three consecutive days.
• Duration: Coverage is limited to a maximum of 100 days per benefit period. For the first 20 days, Medicare typically covers 100% of the cost. From day 21 to 100, a daily coinsurance payment is required.
• Type of care: Coverage applies only to skilled care, such as physical therapy, occupational therapy, or skilled nursing services. Once the need for skilled care ends, Medicare coverage stops, even if the person needs ongoing custodial care.

Home health care

Medicare Parts A and B offer coverage for home health care services, provided certain eligibility requirements are met.

• Homebound status: The person must be considered homebound, meaning they require assistance to leave their home.
• Medically necessary: A doctor must certify the need for part-time or intermittent skilled nursing care, physical therapy, or other skilled therapies.
• Intermittent care: Coverage is for part-time or intermittent skilled care, not continuous or full-time care. A home health aide may also be covered to assist with personal care if skilled services are also being provided.

Hospice care

For terminally ill patients, Medicare Part A provides comprehensive hospice care benefits. This is a special type of care focused on comfort and pain management, not on curing the illness.

• Life expectancy: A doctor must certify that the patient has a life expectancy of six months or less.
• Included services: Coverage includes nursing care, medical equipment, medications for symptom management, and social services. Most costs are covered, though small copayments for prescriptions and respite care may apply.

Potential for enhanced coverage through Medicare Advantage

While Original Medicare has significant gaps in long-term care coverage, Medicare Advantage (Part C) plans offer a different approach. These plans are offered by private companies approved by Medicare and must provide at least the same benefits as Original Medicare, but they often include expanded supplemental benefits.

Supplemental benefits

Since 2019, Medicare Advantage plans have had the flexibility to offer supplemental benefits that address a person's chronic health conditions. These can include:

• In-home support: Non-medical help with daily living activities.
• Adult day care: Services that provide social and health services in a community-based setting.
• Meal delivery: Providing nutritious meals for those unable to cook for themselves.
• Transportation: Non-emergency medical transportation to and from appointments.

Special Needs Plans (SNPs)

For individuals with both Medicare and Medicaid, some Medicare Advantage SNPs are designed specifically to coordinate care and provide enhanced long-term care benefits. These plans can integrate medical, hospital, and long-term services, including home care and adult day care.

Comparison of long-term care coverage options

Feature	Original Medicare (Parts A & B)	Medicare Advantage (Part C)	Medicaid	Private Long-Term Care Insurance
Custodial Care (ADLs)	Generally not covered.	May offer limited supplemental benefits.	Covers for eligible individuals.	Primary purpose is to cover these costs.
Skilled Nursing Facility (SNF)	Limited to 100 days per benefit period after a qualifying hospital stay.	At least same as Original Medicare, may have different cost-sharing.	Covers long-term skilled nursing for eligible individuals.	Coverage depends on the specific policy purchased.
Home Health	Covers intermittent skilled care for homebound individuals.	At least same as Original Medicare, may offer additional services.	Varies by state; may cover broader home- and community-based services.	Coverage depends on the specific policy purchased.
Eligibility	Age 65+ or certain disabilities/conditions.	Requires eligibility for Original Medicare.	Income and asset limits, which vary by state.	Based on health underwriting at time of purchase.
Cost	Premiums, deductibles, and coinsurance apply, especially for extended SNF stays.	Premiums and cost-sharing can vary by plan.	Very low or no cost for eligible individuals.	Premiums are often expensive and based on age and health.

Alternatives to relying on Medicare alone

Given Medicare's limitations for long-term services, planning for future care needs is essential. Several alternatives can help fill the coverage gaps.

1. Medicaid: This government program is a crucial resource for low-income individuals. It provides extensive long-term care benefits, including covering extended nursing home stays and some home- and community-based services. Eligibility is based on strict financial criteria that vary by state.
2. Private Long-Term Care Insurance: This insurance can cover a wide range of services, including custodial care at home, in assisted living, or in a nursing home. These policies are typically purchased well in advance and are underwritten based on your health. The premiums can be high, and some policies have lifetime maximums.
3. Veterans' Benefits: Veterans who qualify may be eligible for long-term care services covered by the U.S. Department of Veterans Affairs (VA). Benefits can include nursing home care and support for aging in place at home. Eligibility varies based on service-connected disability status and other factors.
4. Personal Savings: Using personal savings, investments, or home equity is a common way to pay for long-term care costs. It is a good practice to analyze your financial situation and plan ahead for these potential expenses.

Conclusion: Navigating your long-term care options

When exploring what types of services and care will Medicare provide for long term services, it's clear that the program's primary focus is on acute, medically necessary care, not ongoing custodial support. While Medicare does cover short-term skilled nursing stays, home health services, and hospice, its coverage for truly long-term needs is minimal. To ensure you have access to the care you might need in the future, it is critical to explore alternatives like Medicaid, private long-term care insurance, or specialized Medicare Advantage plans. Understanding these distinctions and planning proactively is the most effective way to secure your healthcare as you age.

For more information on planning for long-term care, you can visit the U.S. Department of Health and Human Services' Administration for Community Living website at https://acl.gov/ltc.

Frequently Asked Questions

Does Medicare pay for nursing home stays for long-term care?

No, Original Medicare generally does not pay for long-term nursing home stays. It will only cover a limited, short-term stay (up to 100 days) in a skilled nursing facility for rehabilitation after a qualifying hospital stay, not for long-term custodial care.

What is the difference between skilled and custodial care?

Skilled care involves services that require the training of a medical professional, such as physical therapy or injections. Custodial care is non-medical assistance with daily living activities like bathing, dressing, and eating.

Can I get home health care indefinitely through Medicare?

No, Medicare's home health benefit is for intermittent or part-time skilled care for a limited duration. It is not intended for continuous, full-time, or long-term nursing care.

Will Medicare pay for assisted living?

Original Medicare does not cover room and board costs at an assisted living facility. Some services provided within an assisted living facility, like skilled nursing or physical therapy, may be covered if they meet specific Medicare requirements.

What if I have a Medicare Advantage plan? Will they provide more long-term services?

Medicare Advantage (Part C) plans may offer expanded supplemental benefits that can include some long-term services, such as in-home support or adult day care. However, these benefits vary by plan, so it is important to check with your specific plan provider.

Are there any Medicare benefits for people with chronic conditions needing long-term services?

While Medicare won't cover long-term custodial care, some benefits may be available if skilled care is required to maintain function and prevent decline, even for chronic conditions like Alzheimer's. Coverage is based on the need for skilled services, not a cure.

How can I pay for long-term care if Medicare won't cover it?

Alternative options include using personal savings, purchasing private long-term care insurance, applying for Medicaid if you meet eligibility requirements, or exploring Veterans' Administration benefits if you are a veteran.