Medicare and Long-Term Care: What’s Covered, What’s Not

Quick summary

One of the biggest myths about Medicare is that it pays for long-term care. It doesn't. Medicare covers only limited periods of inpatient care in a skilled nursing facility, and skilled nursing care and therapy at home, under strict guidelines. Still, Medicare's coverage of these services can be vital if your parent has just been hospitalized or has otherwise suffered a serious medical event. Medicare can pay for your parent's costly short-term, intensive rehabilitation, which in turn can give you a chance to arrange for longer-term care if your parent needs it.

Here are the basics about Medicare coverage for nursing-facility and home care:

Who's eligible for Medicare coverage of nursing-facility and home care?

Medicare coverage of inpatient care in a skilled nursing facility is a standard part of Medicare Part A. If your parent is enrolled in Part A, she doesn't have to do any special paperwork to receive nursing-facility coverage.

Skilled care at home can be covered by either Medicare Part A or Medicare Part B, under slightly different rules. If your parent is enrolled in either Part A or Part B, she can receive coverage for skilled home care without any additional Medicare enrollment.

What kind of nursing-facility care does Medicare cover?

"Nursing home" or "nursing facility" can refer to different levels of inpatient care in different types of places, including rest homes, nursing homes, board-and-care homes, assisted-living facilities, congregate living homes, and sheltered care homes. All of these provide what is called custodial care, which is long-term residence and nonmedical assistance with the activities of daily living -- such as bathing, eating, walking, and dressing -- for people who do not have acute medical conditions but who are no longer able to care for themselves completely. This type of custodial long-term care is not covered by Medicare.

At the other end of the spectrum is a much higher level of inpatient medical care, referred to as skilled nursing or rehabilitation care. Under certain circumstances, Medicare Part A covers this skilled care for a limited time while a patient is recovering from a serious illness, condition, or injury. This care is usually provided in the nursing-facility wing of a hospital, in a separate skilled nursing facility, or in the skilled nursing part of a "multilevel" nursing or rehabilitation facility.

How would my parent qualify for Medicare coverage of nursing-facility care?

In order for your parent to receive Medicare Part A coverage for inpatient nursing-facility care, a number of different conditions have to be met:

• Prior hospital stay: Your parent's stay in a nursing or rehabilitation facility has to begin within 30 days of an inpatient hospital stay of at least three days.
• Need for daily skilled nursing or rehabilitation: Medicare covers an inpatient nursing-facility stay only if your parent needs, and her physician prescribes, daily skilled nursing care or physical rehabilitation. If your parent needs skilled care but doesn't need it every day, Medicare will not cover an inpatient stay; instead, Medicare could cover home care.
• Medicare-approved facility: For Medicare to cover inpatient skilled nursing or rehabilitation care, the care must be received in a facility that Medicare has certified for that purpose.
• Improving condition: Medicare covers inpatient skilled nursing care only as long as your parent's condition is improving. Once Medicare, your parent's doctor, and the facility have determined that her condition has stabilized, Medicare will no longer cover inpatient care.

How much does Medicare pay for a skilled nursing-facility stay?

If, and as long as, your parent meets the qualifying conditions described above, Medicare will pay a limited amount for inpatient nursing-facility care.

For the first 20 days in the facility, Medicare pays all covered charges -- excluding only items like a telephone or television or a private room if not medically necessary.

For days 21 to 100 in a nursing facility during any one benefit period, Medicare pays all covered charges except a daily "coinsurance amount" for which your parent is personally responsible. In 2008, that amount is $128 per day. If your parent is part of a Medicare Part C managed care plan or has a private medigap supplemental insurance policy, that plan or policy might pay some or all of this coinsurance amount.

After 100 days in a covered nursing facility in any one benefit period, Medicare no longer pays any of the cost.

What kind of at-home care does Medicare cover?

If your parent needs skilled nursing or rehabilitation care at home, either Medicare Part A (following a minimum three-day hospital stay) or Part B (no hospital-stay requirement) can cover it. The care may be provided in your parent's home or anywhere else your parent stays. If your parent meets the requirements to qualify for home care (see "How would my parent qualify for Medicare coverage of at-home care?" below), Medicare can cover skilled nursing care and physical and speech therapy as needed while your parent recovers from an illness, condition, or injury. Medicare also covers needed medical supplies and equipment.

Medicare doesn't generally cover nonmedical at-home care and assistance, including meals and housekeeping. However, if your parent is getting Medicare coverage for skilled nursing or therapy at home, Medicare can pay for limited visits by an aide from the home care agency to help your parent with personal care. If Medicare covers skilled care for your parent, it can also cover the services of an occupational therapist to help your parent relearn how to accomplish daily personal care and household tasks safely.

How would my parent qualify for Medicare coverage of at-home care?

For Medicare Part A or Part B to cover your parent's at-home care, several conditions have to be met:

• Need for part-time skilled care: Your parent must have a medical need for, and her doctor must prescribe, skilled nursing care or rehabilitative physical or speech therapy. The care must be needed part-time only, to help recover from a specific illness, injury, or acute condition. If, instead, your parent needs care because of a long-term condition or general frailty, Medicare will not cover it. Nor will Medicare cover full-time or daily care.
• Confinement to home: Medicare covers at-home care only if and for as long as your parent is "confined to home." This means that your parent is unable to leave home without difficulty and with the assistance of another person or a medical device such as a wheelchair. However, it doesn't necessarily mean bedridden.
• Recovery period: At-home care is covered only while your parent is actively recovering, which means while her condition is improving. Once her condition has stabilized, as determined by her physician, the home care agency, and Medicare, coverage ends.
• Medicare-approved agency: Medicare only covers home care provided by a Medicare-certified home healthcare agency. Unfortunately, this leaves out registry nurses, private therapists, and independent caregivers.

How much does Medicare pay for at-home care?

If your parent qualifies for coverage of at-home care, Medicare pays the full amount of the home care agency's charges, except for the rental cost of durable medical equipment such as a wheelchair or hospital bed (for which Medicare pays 80 percent). Your parent's Medicare Advantage managed care plan or medigap insurance policy might pick up this extra 20 percent; otherwise, your parent has to pay for it personally. The home care agency is not allowed to bill your parent for any amount above the Medicare-approved charges.

Medicare doesn't put any specific limit on the number of home care visits it will cover nor on the total number of days your parent can be served by the home healthcare agency. But coverage will continue only as long as your parent meets all of the qualifying conditions for coverage. Your parent's condition and needs are regularly evaluated by the agency and by Medicare itself to determine how long the agency's care is medically needed and thus how long Medicare will keep paying.

Where can I get more information about Medicare coverage for nursing-facility and home care?

If your parent is in the hospital and you're looking for answers about follow-up nursing-facility or home care, contact the hospital's discharge planner, who arranges both of these types of care, or the hospital ombudsman, who is trained in Medicare issues and helps patients understand them.

Whether or not your parent is currently in the hospital, you can get information about nursing-facility and home care coverage directly from Medicare's website or by calling (800) 633-4227. If your parent has been referred to a particular nursing facility or home care agency, the intake administrator for that service can also help with Medicare-related questions or problems.