Does Medicare Pay for Nursing Home Care?
Determining if Medicare pays for nursing home care will likely hinge on several factors, including the nature and duration of the needed care. This article provides a straightforward overview of when Medicare could pay for certain nursing home costs, possible limitations that might exist, and additional insights into funding long-term care.
Key Takeaways
- Medicare may offer limited coverage for nursing home care, possibly covering skilled nursing facilities and short-term stays after a qualifying hospital stay, with certain cost-sharing responsibilities.
- Long-term nursing home care might not be covered by Medicare; instead, alternatives like Medicaid, long-term care insurance, personal resources, and veterans benefits could help manage the possible costs for extended care.
- Supplemental insurance policies like Medicare Advantage and Medigap may offer additional benefits and may help cover out-of-pocket expenses related to nursing home care, but this coverage may vary and should be reviewed carefully.
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The Scope of Medicare and Nursing Home Care
Medicare coverage for nursing home care may not be straightforward. The focus will likely be on skilled nursing facilities and short-term stays, especially those following a qualifying hospital stay. Medicare may cover nursing home care under certain conditions but specific criteria must be met.
To obtain this coverage, members will likely need to have a three-day (or more) inpatient hospital stay. However, the coverage might not be all-encompassing. For the first 20 days of a nursing home stay, Medicare may foot the entire bill. But beyond this, the member will likely have to contribute at least 20% of the cost, with Medicare covering the remaining 80%.
Medicare’s Role in Skilled Nursing Facilities
Medicare’s contribution to skilled nursing facilities may be subject to certain conditions. Some skilled nursing facilities may be covered by Medicare for short-term stays, but there’s a catch. The stay must be linked to the hospital stay, and the admission to the facility must happen within 30 days of hospital discharge.
The services that could be provided by these facilities under Medicare coverage may include inpatient hospital stays, hospice care, and some home health care.
So, while Medicare could assist with skilled nursing facility costs, the coverage might have certain limits.
Short-Term Stays vs. Long-Term Care
Contrary to common belief, Medicare may not provide coverage for long-term nursing home care, instead, it will likely focus on short-term stays post-hospitalization. These short-term stays will likely be determined by a need for rehabilitative care, including skilled services or supplies.
This coverage may be provided when the care required has developed past custodial care, and the stay has been deemed medically necessary. The duration of coverage will likely extend up to 100 days of care in a skilled nursing facility per benefit period. Therefore, it’s imperative to understand the nature of Medicare’s coverage before making any long-term decisions.
Breaking Down Medicare Coverage for Nursing Home Care
The bulk of the coverage for nursing home care may be provided through Medicare Part A, with Part B and Part D offering some coverage for certain services and medications.
However, the coverage from Medicare Part A may also have restrictions. This coverage may only apply when member’s needs have developed past custodial care and may only cater to skilled nursing facilities. Medicare Part B, on the other hand, may not provide coverage for nursing home care, whether inpatient or custodial.
Medicare Part A: Hospital Insurance
Medicare Part A, also known as hospital insurance, could be a prominent contributor in the realm of nursing home care coverage. This option could provide coverage for short-term stays in skilled nursing facilities, but only if they follow a qualifying hospital stay.
This means that the hospital stay must last at least three days, and the care provided by the skilled nursing facility must be for the same or a related condition as the hospital stay.
The coverage under Medicare Part A includes:
- Inpatient hospital stays
- Skilled nursing facility care
- Hospice care
- Some home healthcare services
Keep in mind that while Medicare Part A could serve as a safety net, it may not fully cover all costs associated with nursing home care.
Medicare Part B: Medical Insurance
Although Medicare Part B might not directly cover nursing home care, it could provide significant support for nursing home residents. This could cover a range of medically necessary services, including:
- Clinical research
- Ambulance services
- Durable medical equipment
- Mental health services
- Inpatient and outpatient care
- Diagnostics
- Treatment
For physical therapy in a nursing home, Medicare Part B could cover up to 80% of the expenses. Unlike many other coverage plans, there may not be limitations on the amount of therapy covered under Medicare Part B.
Medicare Part D: Prescription Drug Coverage
Medicare Part D is a voluntary program that could aim to potentially lessen the financial burden of prescription drugs. Implemented by private insurance companies and available to all Medicare-eligible individuals, Part D is the part of Medicare that provides prescription drug coverage.
While in a Part A-covered nursing home stay, some of the prescription drugs may be covered by Medicare Part A, not Part D.
However, the possibility of Medicare paying for other health care and prescription drugs while the individual is in a nursing home will likely depend on the individual’s coverage.
You can enroll in Part A, Part B, or Part D by calling one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST. Our agents can provide comprehensive information, personalized guidance, and ongoing assistance to navigate the enrollment process for private insurance companies, making it easier for beneficiaries to make informed decisions about their healthcare.
Alternatives for Paying for Nursing Home Care
While Medicare may provide some coverage for nursing home care, it isn’t the only option. Other alternatives may include:
- Medicaid
- Long-term care insurance
- Personal resources
- Veterans benefits
Health care costs could also play a role in covering nursing home care costs, and working with an insurance company may provide additional support.
To qualify for Medicaid assistance for nursing home care, individuals must meet certain income requirements and demonstrate a medical need for care. Keep in mind that transferring assets within 60 months of your Medicaid application may result in penalties, potentially causing substantial delays in obtaining coverage.
Long-term care insurance could also aid in covering a variety of services, but the coverage details may also differ.
Medicaid: Financial Assistance for Low-Income Individuals
Medicaid, a program jointly funded by the federal and state governments, will likely aid individuals with limited income and resources in covering some of their medical expenses. This may include providing Medicaid services such as:
- doctor visits
- hospital stays
- prescription medications
- nursing home costs for those who are eligible
If you’re considering this route, it’s recommended to reach out to your state’s Medicaid office for more information.
Long-Term Care Insurance: A Private Option
Long-term care insurance could serve as another resource for covering nursing home care costs. Essentially, it’s an insurance policy that could provide financial help for various forms of long-term care, both skilled and non-skilled.
The coverage may vary significantly between policies. Some insurance policies may only cover nursing home care. Other policies may cover a range of services, including:
- adult day care
- assisted living facilities
- medical equipment
- informal home care
Long-term care insurance plans may cover up to 5 percent of nursing home expenses in the United States. Federal employees, members of uniformed services, retirees, and their spouses may qualify for discounted group rates when purchasing long-term care insurance. This could offer valuable coverage at more affordable prices.
Personal Resources and Possible Veterans Benefits
Utilizing personal resources like savings or life insurance policies may also help in covering nursing home costs. Additionally, veterans could potentially access a variety of benefits that could help pay for nursing home care, such as:
- Aid and Attendance Pension
- Housebound Pension
- Veterans Directed Home and Community Based Services
- State Veterans Homes
- VA Community Living Centers
Pension funds may also be used to cover nursing home costs. Veterans could potentially receive specific advantages for nursing home care, including:
- Access to 24/7 nursing and medical care
- Physical therapy
- Assistance with daily tasks
- Comfort care
They may also qualify for long-term care services such as assisted living, residential, or home health care provided by a licensed medical professional.
The Veterans Administration will likely provide financial assistance for nursing home care based on various factors such as service-connected status, level of disability, and income.
Navigating Medicare Advantage and Medigap Policies
Besides traditional Medicare coverage, other options should be considered. Medicare Advantage and Medigap policies could potentially help cover nursing home costs, but these plans may vary in coverage and costs.
Medicare Advantage plans, privately run health plans, have an agreement with Medicare to provide benefits. They may not cover extended stays in nursing homes or assisted living facilities, but they may cover associated services like skilled nursing and in-home care, as well as prescription drugs in nursing home settings.
On the contrary, Medigap will likely function as supplementary insurance that could aid in covering coinsurance, copayments, and deductibles that may be associated with Original Medicare. While it might not extend coverage to long-term care in nursing homes, it could potentially help offset some of the remaining costs for up to 100 days of nursing home care as outlined in Medicare Part A.
Medicare Advantage Plans: Varying Coverage and Costs
Some of the Medicare Advantage plans may offer a variety of coverages and costs for nursing home care. While they may not directly provide coverage for nursing homes or assisted living, they could potentially include services such as skilled nursing and in-home care, which might not be offered as additional benefits under Original Medicare.
The different categories of Medicare Advantage plans include:
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Medicare Savings Account (MSA)
- Private Fee-for-Service (PFFS)
The coverage these plans might offer and some of the associated costs may differ considerably across various Medicare Advantage plans.
Medigap Policies: Supplementing Medicare Coverage
Medigap policies could serve as a safety net, possibly assisting in covering the remaining 20% of nursing home care costs that might not be covered by Medicare.
There will likely be several Medigap plans that could offer specific benefits for skilled nursing facility care. These plans may include:
- Plan C
- Plan D
- Plan F
- Plan G
- Plan K
- Plan L
- Plan M
- Plan N
However, it’s crucial to review your Medigap policy to comprehend how the coverage could affect your budget, as policy details may vary.
Assessing Other Long-Term Care Options
Nursing homes may not be the only choice for long-term care. Other options could include home health care services, assisted living facilities, and adult day care centers. These options could cater to different needs and preferences, potentially offering a variety of care levels and lifestyle choices.
Choosing the right long-term care option will likely involve assessing safety, socialization opportunities, medical requirements, and the financial aspect of care. It may also be crucial to evaluate the quality of care at assisted living facilities and adult day care centers.
Home Health Care Services
Home health care services could provide a distinctive mix of medical and personal care right at one’s home. These services might include:
- Doctor care
- Nursing care
- Physical or occupational therapy
- Medical social services
Medicare may also provide coverage for home health care services such as skilled nursing care, skilled therapy, and care offered by a home health aide. To qualify for these services under Medicare, individuals must have a face-to-face visit with a doctor or other healthcare provider who certifies the need for such services.
Assisted Living Facilities and Adult Day Care
Assisted living facilities and adult day care centers could cater to seniors needing assistance but not requiring full-time nursing home care. These facilities could offer a greater degree of independence along with assistance for personal needs, whereas nursing homes may offer more extensive medical care for individuals with advanced care requirements.
Assisted living facilities might offer some of the following services:
- Personal care
- Medication management
- Restaurant-style dining
- Scheduled activities
- Security features
- Assistance with daily activities
- Housekeeping services
Adult daycare centers will likely operate during regular business hours and could offer a wide range of services, including:
- Medication monitoring
- Meal and snack provision
- Physical or occupational therapy
- Organizing social activities
Tips for Choosing a Nursing Home and Enrolling in Medicare
Selecting a nursing home and enrolling in Medicare will likely require a careful evaluation of quality, costs, and timing.
While coverage for long-term nursing home care might be limited, Medicare might offer crucial benefits for nursing home residents, such as coverage for certain medications, rehabilitative therapy, and other medically necessary services that may be required during their stay.
To enroll in Medicare for nursing home care coverage, you can call one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST. Enrollment is first available starting 3 months before turning 65 years old.
Some of the Medicare Advantage plans may also provide supplementary benefits to nursing home residents, such as coverage for prescription drugs, and access to services that might not be included in traditional Medicare, such as vision, dental, and hearing services.
Evaluating Nursing Home Quality and Possible Costs
It may be vital to evaluate the quality of care when selecting a nursing home. Some of the primary indicators of quality nursing home care may encompass resident outcomes, assessment of the quality of care, and specific quality measures such as flu shot rates.
The potential cost could be another important factor to consider. The potential cost of nursing homes may vary significantly across different states, as it will likely be influenced by local economic conditions, cost of living, and healthcare infrastructure. Additionally, there may also be hidden costs to be aware of, such as:
- Health assessments
- Leave of absence fees
- State assessments
- Extra services
- Charges for services such as transportation, medication, or equipment.
Timing Your Medicare Enrollment
Scheduling your Medicare enrollment is critical to avoid penalties and secure coverage when required. The initial enrollment period spans 7 months, and delaying enrollment can lead to penalties.
Medicare may provide coverage for up to 100 days of care in a skilled nursing facility per benefit period, which may be contingent upon continued stay in the facility and meeting specific criteria.
Summary
Navigating the complex world of Medicare and nursing home care might be daunting, but with the right information and careful planning, it could be manageable.
From understanding the possible scope of Medicare coverage for nursing home care, and exploring the potential alternatives like Medicaid and long-term care insurance, to timing your Medicare enrollment, every step is towards ensuring the best care for you or your loved ones. Remember, take time to understand, evaluate, and make informed decisions.
Frequently Asked Questions
→ What part of Medicare covers long-term care for whatever the beneficiary might need?
Medicare Part A will likely cover long-term care under certain hospice services when certain conditions have been met. However, it may not cover long-term care for whatever the beneficiary might need.
→ What types of care could Medicare cover?
Medicare will likely cover different types of care through its four parts: Part A may include inpatient hospital care, skilled nursing facility care, and hospice care, while Part B could provide outpatient medical coverage. Additionally, Part D offers prescription drug coverage.
→ How does Medicare Part A contribute to nursing home care coverage?
Medicare Part A will likely cover short-term stays in skilled nursing facilities after a qualifying hospital stay.
→ How does long-term care insurance help in covering nursing home care costs?
Long-term care insurance might help cover nursing home care costs by potentially providing financial assistance for different forms of long-term care, with coverage varying between policies.
→ What are the potential benefits of enrolling in a Medicare Advantage plan for nursing home residents?
Enrolling in a Medicare Advantage plan may provide nursing home residents with supplementary benefits, which might include coverage for prescription drugs and access to services that may not be included in traditional Medicare, such as vision, dental, and hearing services.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.