Medicare does not cover any long-term care in nursing homes, assisted living facilities, or people’s own homes.
Except for minimal circumstances, a person receives home health services through a Medicare-approved agency. Of course, Medicare covers medical services in these settings. But it does not pay for a stay in any long-term care facilities or the cost of any custodial care (that is, help with daily life activities, such as bathing, dressing, eating, and going to the bathroom).
For the most part, if you or a loved one needs long-term care in a nursing facility, an assisted living setting, or your own home, you’re on your own financially.
Medicare will cover “some” short-term stays.
However, there are some limited circumstances when original Medicare will pay for this care for a short time. Receiving treatment in a hospital for an injury or illness that requires rehabilitation, Medicare will pay 100% for care at a skilled nursing facility.
Of course, limitations apply.
If enrolled in original Medicare, that program can pay a portion of the cost for up to 100 days in a skilled nursing facility.
However, You must be admitted to the skilled nursing facility within 30 days of leaving the hospital for the same illness, injury, or a related condition.
The secret handshake: What is a ‘qualifying hospital stay’?
If you want to think of it that way, the catch is that you must have been admitted to a hospital for at least three days before going to a rehab center. Meaning you were formally admitted as an inpatient to the hospital for at least three consecutive days. You cannot have been in “observation” status.
In both cases, you are lying in a hospital bed, eating hospital food, and seeing hospital doctors and nurses. But time spent under observation does not count toward the three-day requirement for Medicare coverage in a skilled nursing facility.
When you enter the hospital, ask if the dr is officially admitting you or if it is for observation only. If the latter is the case, you might want to ask your doctor to move you to inpatient status.
A few more notes about the three-day rule:
- Medicare Advantage plans, which match the coverage of original Medicare and often provide additional benefits, often don’t have those same restrictions for enrollees. Check with your plan provider on terms for skilled nursing care.
- Skilled nursing facilities are the only places that have to abide by the rule. Medicare covers continuous care in a rehabilitation hospital differently than in a hospital.
If you qualify for short-term coverage in a skilled nursing facility, Medicare pays 100 percent of the cost — meals, nursing care, room, etc. — for the first 20 days. After that, it will cover most of the costs of that care for days 21 to 100. You’ll need to cover coinsurance of $185.50 per day in 2020.
You’re responsible for the total amount if you stay more than 100 days in a nursing facility. Unless you have supplementary insurance, like a Medigap policy, that covers it.
Check Please: Who pays for long-term care?
Medicare doesn’t pay anything toward the considerable cost of staying in a nursing home or other facility for long-term care.
So who or what does? Here are some options.
- Private pay: Many individuals and families pay out of pocket or tap assets such as property or investments to finance their own or a loved one’s nursing home care. If they use up those resources, Medicaid may become an option.
- Long-term care insurance: Some people have long-term care insurance that might pay, depending on the terms of their policies.
- The VA: Military veterans may access long-term care benefits from the U.S. Department of Veterans Affairs.
- Medicaid: The state and federal health care program that provides coverage to low-income people who qualify pays a considerable portion of America’s nursing home bills. Medicaid eligibility varies by state but requires strictly limited income and financial assets.
You might be eligible for some financial care that Medicare doesn’t cover. Check out whether your or your family member’s income qualifies for Medicare. Many Americans who need long-term care apply after spending down their resources to the point of qualifying. You can also investigate private long-term care insurance policies. Contact your State Health Insurance Assistance Program for eligibility information.