Medicare provides health care benefits to those who pay into Social Security throughout their careers, which includes coverage for individuals under 65 years of age who are eligible to receive Social Security Disability benefits, as well as those diagnosed with Amyotrophic Lateral Sclerosis (ALS) or permanent kidney disease requiring dialysis or a kidney transplant. However, it may not be clear to many people what Medicare covers when it comes to long-term care, such as nursing home expenses. Therefore, it’s important to understand what Medicare pays for in terms of nursing home care.

Many people wonder whether Medicare covers long-term care, which is a combination of medical and non-medical services provided to individuals who are unable to perform basic daily activities on their own. These activities, also known as activities of daily living (ADLs), include tasks such as bathing, dressing, eating, and managing bowel and bladder functions. Long-term care also involves ensuring that patients have enough physical mobility to move safely between a bed or chair, a process referred to as transferring. Typically, long-term care is provided indefinitely for individuals with chronic illnesses without the expectation of recovery. However, if you’re wondering specifically about whether Medicare pays for nursing care, I can assist you with that question.

Often patients receiving long-term care services reside in a nursing home to be able to have their basic needs met.  For others who have become incapacitated due to an illness or injury, skilled nursing care may be needed with the goal of recovering to independent functional status.  Medicare will pay for medically necessary acute care services and some long-term care services that meet specific criteria.  Most long-term care non-medical services are not covered by Medicare, such as nursing home expenses or the services provided in the home for custodial-type care.

When will Medicare cover skilled nursing care?

For a Medicare recipient to qualify for a skilled nursing home stay, the patient must have a qualifying hospital stay which is when hospital provides acute care in a hospital for three consecutive days (often referred to as three midnights) prior to transferring to a skilled nursing facility or must be placed in a skilled nursing facility within 30 days of that qualifying acute care stay.  Being held on observation status for three consecutive days is not enough for Medicare to pay for additional care.

When Medical Conditions are Deemed Necessary

When a patient meets the criteria above, Medicare will pay for certain services.  Services covered include intermittent or part-time skilled nursing care, therapy services provided by a Medicare-certified home health agency, medical social services, and medical supplies and durable medical equipment (of which 80% of the approved amount is covered).

For patients with conditions that may not improve, such as debility from a stroke, Parkinson’s disease, Alzheimer’s disease, Multiple sclerosis, or ALS, Medicare will pay for services that could prevent further decline in their health status.  Hospice care for those with a terminal illness who have chosen to stop all active treatment and are not expected to survive longer than six months is also covered by Medicare.  This care includes medications for pain control or relief from the symptoms of the illness, as well as hospice care by a Medicare-approved hospice provider not only in the home but in a nursing home or a hospice care facility.   Lastly, some short-term hospital visits may be covered.

How much will I have to pay if I’m in a skilled nursing facility (nursing home)?

If you are in a skilled nursing facility, your Medicare coverage may pay for your stay, but the amount you pay out of pocket will depend on how long you are eligible to receive care. During each benefit period, you will have to make copayments as follows:

• Days 1 to 20 – No copayment required.
• Days 21 to 100 – Copayment of up to $200 per day (in 2023).
• Days 101 and beyond – You are responsible for the total cost!

To offset the costs of copayments for days 21 to 100, you may want to consider a Medicare supplemental policy (also known as Medigap), retiree coverage or other insurance. These policies can provide additional coverage and reduce your out-of-pocket expenses.

Paying for nursing care once Medicare coverage expires (or if no medicare coverage is avaialble), the help of a knowledgeable elder law attorney can be essential to help patients and their families navigate the process of paying for care and qualifying for Medicaid.

Understanding how to pay for long-term care can be overwhelming. We help seniors and their loved ones plan for the possibility of needing long-term care, including how to access and pay for it. If we can be of assistance, please contact us today at (717) 232-4701 to schedule a free consultation to discuss your legal matters.