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Long-Term Care

Does Medicare Cover Long-Term Care?

With life expectancies rising, long-term care needs are growing rapidly. According to the Department of Health and Human Services (HHS), over 10 million Americans need at least some level of long-term care. Of those, over one-third are under the age of 65.

In this post, we define long-term care, describe common risk factors, and explain Medicare coverage.

What Is Long-Term Care?

When we talk about long-term care, we’re using the HHS definition: the supports and services required “to meet your personal care needs.” These tasks are broken into two categories: activities of daily living (ADL) and instrumental activities of daily living (IADL).

ADLs are the minimum tasks required in daily life. They include:

  • Bathing and dressing yourself
  • Eating
  • Getting into or out of a chair or bed
  • Using the toilet or incontinence care

IADLs are also a part of daily life, though not so basic as the above list of tasks. They include:

  • Household chores
  • Managing finances
  • Meal prep and cleanup
  • Pet care
  • Responding to alarms (e.g. smoke or fire alarm)
  • Shopping
  • Taking medication
  • Using communication devices (telephone, TTY, etc.)

Long-term care isn’t about medical care or insurance. It’s about everyday tasks.

Who Needs Long-Term Care?

HHS expects the majority of people who turn 65 to eventually need some type of long-term care. The following risk factors increase your need for long-term care, paid or otherwise:

  • Risk increases with age
  • Chronic illness and accidents raise your risk of disability, which makes you more likely to need long-term care
  • People who have high blood pressure, diabetes, or generally unhealthy lifestyles are more likely to need long-term care
  • Women tend to live slightly longer than men, raising their risk

When it comes to requiring paid professional care, the greatest risk factor is living alone.

What Long-Term Care Needs Does Medicare Cover?

Defining what Medicare does and doesn’t cover is a bit tricky, as there are numerous requirements for the items they do cover.

Physical therapy long-term care

First, Medicare does not cover ADL or IADL assistance if that is the only care you need. Basically, if it’s care you would receive in a nursing home or assisted living facility, Medicare probably won’t cover it. Medicare only covers long-term care that has been prescribed by a doctor and fulfills very specific requirements, which mainly have to do with time, meaning that your doctor expects you to get well with treatment.

Long-term care hospitals

Long-term care hospitals (LTCH) are covered under your Medicare Part A insurance. To get this coverage, your doctor must expect your condition to improve with care and time AND you have more than one serious condition.

Your costs are usually the same as with an acute care hospital. If you fall within the same benefit period, you have no additional deductible. Admittance more than 60 days after being discharged from an acute care hospital, however, starts a new benefit period.

Skilled nursing facility care

Your Part A insurance also covers skilled nursing care (i.e. care that must be given by a registered nurse or doctor) if it’s provided in a skilled nursing facility for a limited time and you meet certain conditions. Medicare coverage includes a variety of services, such as meals, a semi-private room, and medically-prescribed treatments and medications.

Home health services

Both Part A and Part B cover qualifying home health services deemed medically necessary. This includes part-time or intermittent skilled care from either a nurse or a home health aide, speech-language pathology, and physical and occupational therapy.

Medicare does not cover 24-hour home care, meal delivery, personal care when that is the only care required, or personal services such as laundry and shopping.

To qualify, you must be under a doctor’s care and have a care plan that details the services required. In addition, your doctor must certify that you qualify for at least one of the following:

  • Intermittent skilled nursing care beyond blood draws
  • Physical or occupational therapy and/or speech-language pathology services that are effective in treating your condition and complex enough to require professional assistance
  • You are homebound

Homebound patients are permitted to leave their homes for medical treatment as well as for short, infrequent non-medical reasons.

Before beginning home health care, ask the agency how much Medicare will pay and whether any items or services you require are not covered by Medicare. Ask for these details in writing. The agency should notify you via an Advance Beneficiary Notice of Noncoverage before providing supplies or services not covered by Medicare.

Hospice and respite care

Medicare covers hospice care at either your home or in a hospice inpatient facility. To qualify as hospice care, you must have a terminal illness with a prognosis of fewer than six months, as certified by your doctor. If at any point you decide you want to treat your illness rather than accept palliative care, talk to your doctor. Before beginning any treatment designed to cure your illness, you must also inform to your hospice team. Otherwise, you may be responsible for any charges related to said treatment, including prescription drugs.

Paying for long-term care

Other Options to Pay for Long-Term Care

As Medicare covers relatively few long-term care expenses, you may want to look at other options for paid care.

  • The Medicaid program covers many long-term care costs. However, you must meet eligibility requirements, which differ in each state.
  • Veterans Aid and Attendance is a benefit intended for military veterans and their surviving spouses. Requirements include military service as well as limitations regarding net worth and income. Disability and level of care requirements also apply.
  • Long-term care insurance is also available through private insurers.

Some Medigap plans also help with long-term care costs. If you have questions about your Medigap plan, or about adding one, call us toll-free at 855-350-8101 to speak to a licensed agent.

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