Approximately 63% of individuals age 65 and older will require extra care at some point throughout their lifetime, and with average life expectancy rising and the population of those 65 and older growing rapidly, that need is expected to rise as well.
Long-term care isn’t one specific service covered by your health insurance. Long-term care services are those that aid in supporting health, finances, living accommodations, and helping you navigate legal, family, and other dynamics that come with it. The specific long-term care services someone may need will be unique to that person’s health, lifestyle, and financial status.
Therefore, it’s important to plan ahead and know what long-term care options Medicare may or may not cover, as well as what other resources exist to help you obtain the comprehensive long-term care you need.
What does Medicare cover for long-term care?
In general, Original Medicare (Parts A & B) does not pay for most long-term care services or for personal care services such as custodial care. There are some specific circumstances when Medicare will cover certain long-term care services.
NOTE:For all of the situations below, if you have a Medicare Advantage plan, your cost-sharing rules may be different. You need to check with the plan provider to understand how long-term care services may be covered and how your costs may vary.
Medicare may cover a skilled nursing facility stay if you need long-term care after being in the hospital
Medicare Part A will help pay a portion of the costs for a short stay (up to 100 days per benefit period) in a skilled nursing facility if you meet all of the following conditions:
- You were admitted to the hospital with an inpatient stay of three days or more
- You need skilled care such as physical therapy or skilled nursing services
- The nursing facility you will be admitted to is Medicare-certified
- You are admitted to the Medicare-certified nursing facility within 30 days of your inpatient hospital stay
The amount that Medicare will pay varies based on the number of days you are in the facility. During each benefit period, the following coverage rules apply for Part A.
- Medicare will pay 100% of the cost for days 0–20
- For days 21–100, you will pay a daily copayment (which can change each year — view the most up-to-date Part A costs here) and Medicare will pay the rest
Medicare may help with some long-term services if they’re medically necessary to treat an illness or injury
Medicare Part A or Part B may cover various long-term care services and items as long as they’re deemed medically necessary to treat an illness or injury. The following may be covered on an ongoing basis if (1) they remain a medical necessity and (2) your doctor reorders them for you every 60 days
- Intermittent or part-time skilled nursing care
- Physical therapy, occupational therapy, or speech-language pathology services
- Medical social care services that help you cope with social, psychological, cultural, or other medical issues that may rise from an illness
- Medical supplies
- Durable medical equipment
People suffering from a stroke, Alzheimer’s, Parkinson’s, ALS, or Multiple Sclerosis may get additional coverage
Certain medical conditions may provide for additional coverage from Medicare. Medicare may cover long-term services to help prevent further decline due to medical conditions that may not improve over time, such as a stroke or Alzheimer’s disease. You’ll want to check with Medicare or your Medicare plan provider to understand what services may be offered and how cost sharing works.
Medicare Part A and hospice care
A special long-term care service, hospice care is unique in that Medicare Part A will cover 100 percent of your hospice care costs. Generally, you’ll only be responsible for a $5 copay per prescription for any outpatient drugs for pain and symptom management. (In some cases, although it’s rare, your hospice benefits may not cover a certain drug, and you may need to see if your Part D coverage does). Some people may also pay 5 percent of the Medicare-approved amount for inpatient respite care.
Click here to learn how more about hospice care with Medicare, including how to qualify for Medicare-covered hospice, what hospice benefits Medicare will cover, and what Medicare will not cover once you are receiving hospice benefits.
Medicaid, Veterans Affairs benefits, and other state programs may also provide long-term care
Medicare may not be your only option for long-term care services. Medicaid also covers long-term care services provided in nursing homes or at home.
Medicaid may offer more long-term care services, including custodial care
Medicaid can also cover some long-term care services that Medicare does not, such as custodial care. But, because Medicaid programs are state-specific, you’ll need to check with your state’s Medicaid office to understand if you qualify, and if you do, how your state’s Medicaid program coverage works. Some states offer additional benefits beyond those that are federally required. Here’s a helpful link from the Administration for Community Living on Medicaid and long-term care.
Eligible veterans may get long-term care services paid for by the VA
Veterans with service-related disabilities and other eligible qualifications may be able to get long-term care services paid for by the Department of Veterans Affairs. The VA may provide nursing home care, at-home care for aging veterans with long-term care needs, and more. Veterans who do not have a service-related disability, but who are unable to pay for the cost of necessary care, may also be able to get the VA to pay for long-term care services. In addition, veterans may be able to benefit from two other care programs: The Housebound Aid and Attendance Allowance Program, and a Veteran Directed Home and Community-Based Services program (VD-HCBS). Get more information here about long-term care as a veteran.
Your state may have additional programs that could help
Many states have specific programs designed to help older adults remain in their communities and be as independent as possible. Programs vary by state, but are usually funded by county, state, and federal sources (like the Older Americans Act) and administered through state and local agency networks (the Aging Network). The services provided can vary but often include things like nutrition programs, transportation services, personal care assistance, and family caregiver services and supports.
These programs typically have financial eligibility criteria — and generally are designed to target low-income, frail seniors over age 60, minority older adults, and seniors who live in rural areas.
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