Paying for Long Term Care

Medicare

Medicare is a federal health insurance program for people 65 and over and certain disabled people under 65. It does not provide a comprehensive long term care component and generally does not cover assisted living costs but may pay for short term services (e.g. physical and other therapies) contracted through a home health care agency and provided to the resident at the assisted living facility. Medicare covers only those skilled nursing facility services rendered to help a beneficiary recover from an acute illness or injury. Medicare is administered by the federal government's Centers for Medicare and Medicaid Services (CMS) and is divided into two parts: Hospital Insurance (Part A); and Medical Insurance (Part B).

Eligibility

Nursing facility coverage falls under Part A of Medicare and is very limited. If certain conditions are met, Medicare only pays fully for the first 20 days of care in a skilled nursing facility (SNF).

For the 21st through the 100th day, the patient must share, or co-pay, for the cost of care by paying a daily coinsurance rate, which changes yearly. In 2002 the coinsurance payment is just over $101 per day.

Medicare Pays for Nursing Facility Care Only Under the Following Conditions:

  1. The nursing home is a skilled nursing facility (SNF). SNFs provide 24-hour nursing care to convalescent patients.
  2. Continuous skilled nursing care or skilled rehabilitation services (as defined by the federal government) are required on a daily basis.
  3. The patient has spent at least three consecutive days in a hospital and if the admission to the SNF occurs within 30 days after discharge from the hospital.
  4. A physician certifies that SNF services are needed for the same or related illness for which the person was hospitalized.

Services Covered by Medicare

  • A semi-private room
  • Meals, including special diets
  • Regular nursing services
  • Rehabilitation services
  • Drugs furnished by the facility
  • Medical supplies

Services Not Covered by Medicare

  • Personal convenience items
  • Private duty nurses
  • Extra charges for a private room

Medicare Part B may help pay for covered services you receive from your doctor in a SNF, if you choose to participate in the Part B medical insurance program. If you have used up your Part A coverage for a spell of illness, Part B also covers a portion of services received in a SNF, such as physical and occupational therapy. Under the Part B program, you must pay an annual premium and a deductible for all Part B services, including physician services, after which Medicare pays 80 percent of the reasonable charges for covered services.

Services Not Included Under Medicare Part B

  • Routine physical examinations and tests
  • Routine foot care
  • Eye or hearing exams for prescribing or fitting eyeglasses or hearing aids
  • Immunizations other than for the flu or pneumonia

How to Apply for Medicare

Contact your nearest Social Security office to find out if you are automatically covered for Part A because of credits for the number of (calendar) quarters worked in your lifetime. Also, if you are interested in signing up for Medicare medical insurance (Part B), the Social Security office can assist you with that process. Keep in mind, though, that you can only sign up for the insurance in the first three month of the calendar year.

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