A Guide to Medicare’s Long-Term Care Coverage

At 65, most people begin receiving Medicare benefits as a result of paying into Social Security throughout their careers. Individuals under age 65 who qualify to receive Social Security Disability benefits are also covered under Medicare, as well as anyone of any age who has Lou Gehrig’s disease, known as Amyotrophic Lateral Sclerosis (ALS), or has been diagnosed with permanent kidney disease (end-stage renal disease) that requires dialysis or a kidney transplant.  But many people may not understand what is covered when long-term care is needed.

In general, long-term care is medical and non-medical care provided to a person who is unable to perform the basic actions needed on a daily basis to function independently.  These basic actions are called activities of daily living and include bathing, dressing, eating, toileting, managing bowel and bladder function, and having enough physical mobility to be able to move safely to and from a bed or a chair, called transferring.  For people with chronic diseases, permanent injury such as from a stroke, or suffering from the effects of aging, long-term care is provided indefinitely without the expectation that the patient will recover.

Often patients receiving long-term care services reside in a nursing home to be able to have their basic needs met.  For others who have become incapacitated due to an illness or injury, skilled nursing care may be needed with the goal of recovering to independent functional status.  Medicare will pay for medically necessary acute care services and some long-term care services that meet specific criteria.  Most long-term care non-medical services are not covered by Medicare, such as nursing home expenses or the services provided in the home for custodial-type care.

There are four specific types of long-term care services, listed below, that Medicare will pay for, though certain conditions apply for most services to be covered:

• Care in a skilled nursing facility for up to 100 days per benefit period
• Services to treat medical conditions
• Services to prevent further decline due to medical conditions
• Hospice care

For a Medicare recipient to qualify for a skilled nursing home stay, the patient must have been provided acute care in a hospital for three consecutive days (often referred to as three midnights) prior to transferring to a skilled nursing facility or must be placed in a skilled nursing facility within 30 days of that qualifying acute care stay.  Being held on observation status for three consecutive days is not enough for Medicare to pay for additional care.

Once in a skilled nursing home, payment for services is based on length of stay with only a portion of the cost covered after the first 20 days, and Medicare will not pay for the cost of the skilled nursing facility after the 100^th day.  These days of stay do not need to be consecutive.

When services to treat medical conditions are deemed medically necessary by a physician, Medicare will pay indefinitely for certain services as long as the physician writes an order for continued services every 60 days and these services remain medically necessary.  Services covered include intermittent or part-time skilled nursing care, therapy services provided by a Medicare-certified home health agency, medical social services, and medical supplies and durable medical equipment (of which 80% of the approved amount is covered).  For patients with conditions that may not improve, such as debility from a stroke, Parkinson’s disease, Alzheimer’s disease, Multiple sclerosis or ALS, Medicare will pay for services that could prevent further decline in their health status.  Hospice care for those with a terminal illness who have chosen to stop all active treatment and are not expected to survive longer than six months is also covered by Medicare.  This care includes medications for pain control or relief from the symptoms of the illness, as well as hospice care by a Medicare-approved hospice provider not only in the home but in a nursing home or a hospice care facility.  Lastly, some short-term hospital visits may be covered.

Understanding how to pay for long-term care can be overwhelming. We help seniors and their loved ones plan for the possibility of needing long-term care, including how to access and pay for it. If you would like to discuss your particular situation, please contact our New York office or call us at 607-271-9270. We look forward to the opportunity to work with you.