Long Term Care and Medicare

Surprises can be a wonderful thing, until it comes to the Long-Term Care (LTC) of a loved one. Some may know that Medicare Part A covers skilled care in a nursing home, but there are limitations to this benefit that will be an unwelcome surprise to many.

To qualify for the Medicare long-term care in a nursing home benefit, a patient must first spend a minimum of three days in a hospital. After the three days or more in a hospital, the patient with Medicare Part A has up to one hundred inpatient skilled nursing days in a benefit period covered. This does not mean that one hundred days in a skilled nursing home are covered. Only the days when a patient is receiving skilled care and continues to recover from an illness or accident are covered. Skilled care includes speech and physical therapy, nurses and occupational therapists.

Medicare does not cover “activities of daily living.” An individual may remain in a nursing home because it would not be safe for them to return home. Possibly the patient cannot dress themselves, use the restroom, prepare food, shower, or walk without assistance. These are activities of daily living and assisting with such activities is referred to as “custodial.” Medicare does not pay for custodial care. Custodial care is paid for by having a private Long-Term Care (LTC) insurance policy. Another way to pay for custodial care is to exhaust the majority of the patient’s assets, thus qualifying for Medicaid. There are state-based programs and law firms that specialize in LTC benefits, but all roads lead to the exhaustion of personal assets first before state aid kicks in. In addition, the state and/or law firm will want their money back after the patient passes away, the estate on the hook for any balance owed.

The family of a loved one recently admitted into a skilled nursing center after a hospital stay is usually surprised to learn of the Medicare coverage limitations when it comes to long-term care. This is exactly the wrong time for surprises, of course. Avoiding such surprises in the first place requires planning ahead. Purchasing LTC insurance while healthy is the prudent and affordable choice.

Lastly, Medicare fully covers the first twenty days in a nursing home or skilled facility. You will pay nearly $200 a day out of pocket for days 21-100 if you don’t have a Medicare supplement plan such as Blue Cross Blue Shield of Arizona Senior Security G plan. After 100 days per benefit period Medicare does not pay. A new benefit period begins when a patient hasn’t used Medicare Part A services for 60 days and then enters the hospital for 3 or more days. A Medicare supplement plan will not cover costs after the 100 days either, hence the need for a private Long-Term Care policy.