Medicare - Is It Enough to Cover Long-Term Care Needs?

Will Medicare Help Pay Long-Term Care Costs?

What is Medicare?
Medicare is a federal program administered by the Center For Medicare and Medicaid. It is available to people at age 65 or those with end stage renal disease.

The Two Parts to Medicare:
PART A covers hospitalizations, skilled nursing care, home health care and hospice. There is no charge for Medicare Part A benefits for those who have 39 or more quarters of Social Security coverage. Those with less than 39 quarters can buy Part A coverage.

PART B covers doctor and medical services, equipment, therapies, lab tests and x-rays. Part B is an optional benefit and has a monthly cost that is determined each year by Social Security.

HMO's
HMO's are required by law to offer the same benefits that Medicare offers. Many HMO's offer additional ancillary benefits like vision and prescription benefits so people will sign over their Medicare benefits.

What is Skilled Care?
This coverage is designed to pay for acute medical care needs and short term, rehabilitative care. This type of care (called skilled care) is provided by licensed professionals. An example would be physical therapy after a stroke, or IV therapy.

Medicare pays for care in skilled nursing facilities, and for home health care. Medicare does not pay for long-term care. Long-term care is when people need assistance with activities of daily living or supervision due to a cognitive impairment. Medicare was not set up to cover chronic conditions.

Medicare Skilled Nursing Facility Benefits
To be eligible for Medicare benefits in a skilled nursing home facility, the applicant must meet the following requirements:

3 day hospital stay (not including the day of discharge)
Care needed must be skilled nursing or skilled rehabilitation services
Skilled Nursing Facility must be certified by Medicare.
Physician must certify the need for this skilled care on a daily basis

If the applicant meets all of these criteria, they can qualify for UP TO 100 days of Medicare benefits. Days 1-20 Medicare will pay at 100%. Days 21-100 Medicare requires a co-pay from the insured. Medicare Supplement or HMO policies may cover this.

In 1999, the average Medicare stay was only 23 days. A full 100 days of skilled care is rarely needed. When skilled care is no longer needed, the care becomes custodial care. Custodial care is not covered by Medicare.

Medicare Home Care Benefits
Medicare will only pay when skilled services needed. Only part time or intermittent home health care is covered. Medicare pays ONLY for regular service visits, NOT for custodial care. Home care aid services are defined as custodial care. Qualified benefits are as follows:

Medicare defines intermittent care as skilled nursing care that is provided on fewer than seven days each week, or less than eight hours each day (combined) for 21 days or less.
The patient must be home-bound. This is defined as a medical condition restricting the ability to leave the house except with assistance- or if it is medically inadvisable to leave the house.
The patient must be under a physician's care and the physician must certify the need for the home health care.
The home health care agency providing the services must be certified by Medicare.

No co-payments are required for home care services paid under Medicare.

Medicare Supplements
Medicare doesn't cover everything, so there are policies that try to fill some of the gaps.

Ten standard types of Medicare Supplement (Medigap) policies are available. The coverage they offer is paying the co-insurance amounts listed above.

Be aware that these supplements only cover Medicare qualifying expenses. If Medicare is not paying, then Medicare Supplements won't, with few exceptions, pay either.

Call the Social Security Administration at 800-772-1213 if you have questions about Medicare. They can answer questions about eligibility.

To request a quote, click here. • For site feedback, click here.