Does Medicare Pay for Nursing Home Care?
Determining if Medicare pays for nursing home care hinges on several factors, including the nature and duration of the needed care. This article provides a straightforward overview of when “does Medicare pay for nursing home” costs might be covered, what limitations exist, and additional insights into funding long-term care.
Key Takeaways
- Medicare offers limited coverage for nursing home care, covering skilled nursing facilities and short-term stays after a qualifying hospital stay, with a 100-day limit per benefit period and certain cost-sharing responsibilities.
- Long-term nursing home care is predominantly not covered by Medicare; instead, alternatives like Medicaid, long-term care insurance, personal resources, and veterans benefits can help manage costs for extended care.
- Supplemental insurance policies like Medicare Advantage and Medigap may offer additional benefits and help cover out-of-pocket expenses related to nursing home care, but their coverage varies and should be reviewed carefully.
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The Scope of Medicare and Nursing Home Care
Medicare coverage for nursing home care doesn’t follow a straightforward path. The focus is mainly 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.
The ticket to this coverage is a three-day (or more) inpatient hospital stay, essentially a prerequisite to unlock Medicare’s contribution towards nursing home costs. However, even with this key, the coverage isn’t all-encompassing. For the first 20 days of a nursing home stay, Medicare will foot the entire bill. But beyond this, the member has to contribute 20% of the cost, with Medicare covering the remaining 80%.
Medicare’s Role in Skilled Nursing Facilities
Medicare significantly contributes to skilled nursing facilities, subject to certain conditions. These skilled nursing facilities are 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 provided by these facilities that Medicare covers include inpatient hospital stays, hospice care, and some home health care. But the coverage isn’t eternal. It lasts for up to 100 days within each benefit period, and a new benefit period only kicks in if there’s a 60-day gap where no skilled care is received in the facility.
So, while Medicare does assist with skilled nursing facility costs, the coverage has its limits.
Short-Term Stays vs. Long-Term Care
Contrary to common belief, Medicare doesn’t provide coverage for long-term nursing home care, instead, its focus is on short-term stays post-hospitalization. These short-term stays are determined by a need for rehabilitative care, including skilled services or supplies.
The coverage is given when the care required is more than just custodial care, and the stay is deemed medically necessary. The duration of coverage extends 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
Having understood the scope of Medicare’s role in nursing home care, we can delve deeper into its coverage components. The bulk of the coverage for nursing home care is primarily through Medicare Part A, with Part B and Part D chipping in to cover some additional services and medications.
However, the coverage from Medicare Part A has its restrictions. It only applies to cases where custodial care isn’t the only requirement and mainly centers around skilled nursing facilities. Medicare Part B, on the other hand, doesn’t provide coverage for nursing home care, whether inpatient or custodial.
So, while Medicare Parts B and D contribute to the coverage pool, they’re more supportive actors, with Part A taking the lead role.
Medicare Part A: Hospital Insurance
Medicare Part A, also known as hospital insurance, is a key player in the realm of nursing home care coverage. It provides 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 health care services
Keep in mind that while Medicare Part A serves as a safety net, it doesn’t fully cover all costs associated with nursing home care.
Medicare Part B: Medical Insurance
Although Medicare Part B doesn’t directly cover nursing home care, it provides significant support for nursing home residents. It covers 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. And the good news doesn’t stop there. Unlike many other coverage plans, there are no limitations on the amount of therapy covered under Medicare Part B.
So, while it might not cover the nursing home stay itself, Medicare Part B can be a valuable resource.
Medicare Part D: Prescription Drug Coverage
Medicare Part D is a voluntary program that aims to 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, prescription drugs are generally covered by Medicare Part A, not Part D.
However, Medicare may pay for other health care and prescription drugs while the individual is in a nursing home, depending on their coverage. Enrolling in Medicare Part D is fairly straightforward, with several methods available.
Alternatives for Paying for Nursing Home Care
While Medicare does provide some coverage for nursing home care, it isn’t the only option. Alternatives such as:
- Medicaid
- Long-term care insurance
- Personal resources
- Veterans benefits
Health care costs can also play a role in covering nursing home care costs, and working with an insurance company may provide additional support.
In order 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 can result in penalties, causing substantial delays in obtaining coverage.
Long-term care insurance can also aid in covering a variety of services, but note that the coverage details can differ.
Medicaid: Financial Assistance for Low-Income Individuals
Medicaid, a program jointly funded by the federal and state governments, aids individuals with limited income and resources in covering their medical expenses. This includes providing Medicaid services such as:
- doctor visits
- hospital stays
- prescription medications
- nursing home costs for those who are eligible
To qualify for Medicaid coverage for nursing home care, individuals typically have to meet specific income and personal resource criteria. For example, in 2023, the monthly income limit for Medicaid eligibility in most states is $2,742 for single individuals and $5,484 for married spouses, with asset limits of $2,000 for singles and $3,000 for couples.
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 serves as another resource for covering nursing home care costs. Essentially, it’s an insurance policy that provides financial help for various forms of long-term care, both skilled and non-skilled.
The coverage can 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
However, it’s worth noting that the cost of long-term care insurance can be a significant consideration. For instance, a single 55-year-old male can expect to pay around $950 per year, while a single 55-year-old woman can expect to pay around $1,500 per year.
Long-term care insurance plans typically cover 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 Veterans Benefits
Utilizing personal resources like savings or life insurance policies can also help in covering nursing home costs. Additionally, veterans can access a variety of benefits to 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 can be used to cover nursing home costs. Veterans 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 provides financial assistance for nursing home care based on 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 can help cover nursing home costs, but these plans vary in coverage and costs.
Medicare Advantage plans, privately run health plans, have an agreement with Medicare to provide benefits. They generally don’t 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 functions as supplementary insurance to aid in covering coinsurance, copayments, and deductibles associated with Original Medicare. While it doesn’t extend coverage to long-term care in nursing homes, it can help offset 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
Medicare Advantage plans 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 can include services such as skilled nursing and in-home care, which are not usually 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 they offer and the associated costs can differ considerably across various Medicare Advantage plans.
The typical expense associated with Medicare Advantage plans for nursing home coverage is $18 per month, but it can vary significantly based on the plan’s specific benefits and coverage options.
Therefore, it’s essential to verify with the Medicare Advantage administrator the medicare pay before making any decisions concerning skilled nursing home care.
Medigap Policies: Supplementing Medicare Coverage
Medigap policies serve as a safety net, assisting in covering the remaining 20% of nursing home care costs that are not covered by Medicare. Some policies also provide coverage for the nursing home coinsurance for days 21 through 100.
There are several Medigap plans that offer specific benefits for skilled nursing facility care. These plans 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 will affect your budget, as policy details can vary.
Assessing Other Long-Term Care Options
Nursing homes are not the sole choice for long-term care. Other options include home health care services, assisted living facilities, and adult day care centers. These options can cater to different needs and preferences, offering a variety of care levels and lifestyle choices.
Choosing the right long-term care option involves assessing safety, socialization opportunities, medical requirements, and the financial aspect of care. It’s also crucial to evaluate the quality of care at assisted living facilities and adult day care centers.
Home Health Care Services
Home health care services provide a distinctive mix of medical and personal care right at one’s home. These services can include:
- Doctor care
- Nursing care
- Physical or occupational therapy
- Medical social services
Medicare provides coverage for home health care services including 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 health care provider who certifies the need for such services.
Assisted Living Facilities and Adult Day Care
Assisted living facilities and adult day care centers cater to seniors needing assistance but not requiring full-time nursing home care. These facilities offer a greater degree of independence along with assistance for personal needs, whereas nursing homes offer more extensive medical care for individuals with advanced care requirements.
Assisted living facilities commonly offer the following services:
- Personal care
- Medication management
- Restaurant-style dining
- Scheduled activities
- Security features
- Assistance with daily activities
- Housekeeping services
The average cost of assisted living in the United States is approximately $4,500 per month, which translates to $54,000 annually.
Adult day care centers operate during regular business hours and 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 is a task that requires careful consideration. It’s a process that requires careful evaluation of quality, costs, and timing.
While coverage for long-term nursing home care is limited, Medicare offers crucial benefits for nursing home residents, such as coverage for certain medications, rehabilitative therapy, and other medically necessary services required during their stay.
To enroll in Medicare for nursing home care coverage, individuals can sign up online at the Social Security website or call Social Security at 1-800-772-1213. Enrollment is first available starting 3 months before turning 65 years old.
Medicare Advantage plans can provide supplementary benefits to nursing home residents, such as coverage for prescription drugs, and access to services not included in traditional Medicare, such as vision, dental, and hearing services.
Evaluating Nursing Home Quality and Costs
It’s vital to evaluate the quality of care when selecting a nursing home. Primary indicators of quality nursing home care encompass resident outcomes, assessment of the quality of care, and specific quality measures such as flu shot rates.
Cost is another important factor to consider. The cost of nursing homes can vary significantly across different states, influenced by local economic conditions, cost of living, and healthcare infrastructure. Additionally, there are 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 provides coverage for up to 100 days of care in a skilled nursing facility per benefit period, contingent upon continued stay in the facility and meeting specific criteria. Therefore, aligning Medicare coverage periods with nursing home care needs is a vital part of the planning process.
Summary
Navigating the complex world of Medicare and nursing home care can be daunting, but with the right information and careful planning, it’s manageable.
From understanding the scope of Medicare coverage for nursing home care, exploring alternatives like Medicaid and long-term care insurance, to timing your Medicare enrollment, every step is a stride towards ensuring the best care for you or your loved ones. Remember, the journey is not a race, but a marathon—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 covers long-term care, including custodial care, under hospice services when certain conditions are met. It does not cover long-term care for whatever the beneficiary might need.
→ What types of care does Medicare cover?
Medicare covers different types of care through its four parts: Part A includes inpatient hospital care, skilled nursing facility care, and hospice care, while Part B provides outpatient medical coverage. Additionally, Part D offers prescription drug coverage (source: medicare.gov).
→ How does Medicare Part A contribute to nursing home care coverage?
Medicare Part A covers short-term stays in skilled nursing facilities after a qualifying hospital stay. It contributes to nursing home care coverage by providing this important short-term support.
→ How does long-term care insurance help in covering nursing home care costs?
Long-term care insurance helps cover nursing home care costs by providing financial assistance for different forms of long-term care, including skilled and non-skilled services, with coverage varying between policies.
→ What are the benefits of enrolling in a Medicare Advantage plan for nursing home residents?
Enrolling in a Medicare Advantage plan can provide nursing home residents with supplementary benefits, including coverage for prescription drugs and access to services not 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.