In a guide to Medicare and long-term care, we have to first answer: what is Medicare?
It’s the United States’ health insurance program for people who are 65 and older. Easy, right? Figuring out what exactly is covered, and what isn’t, is a little bit harder though.
It also gets more complicated when we look at each state’s requirements, Medicare Part A, Medicare Part B, and so on. Lucky for you, we’ve done the research and asked our experts all about Medicare in Texas and how it works with long-term care to bring you this easy guide.
Medicare Part A
This covers skilled nursing facilities and home health care. It’s important to note that Medicare Part A only covers skilled nursing services and not personal care. On their website, they call personal care “custodial care.” This includes bathing, dressing, eating, and other activities of daily living.
There are also requirements you have to meet to be eligible for coverage for skilled nursing care:
- Days left in your benefit period
- A qualifying hospital stay
- Doctor referral
- Receive skilled nursing services in a facility that is certified by Medicare
- Require skilled nursing services for a medical condition that was hospital-related or started while you received care in the skilled nursing facility for a hospital-related medical condition.
What about skilled nursing facilities? What do they offer? Most offer semi-private rooms, meals, skilled nursing care, physical and occupational therapy, speech-language pathology services, medical social services, medications, medical supplies and equipment, ambulance transportation, and dietary counseling (all of which are covered by Medicare Part A.)
Another thing we’d like to point out is how the benefit period works. For days 1-20, you pay $0. Days 21-100, you pay $167.50 coinsurance per day of each benefit period. Days 101 and beyond, you pay all costs.
Medicare Part B
Medicare Part B does not cover long-term care. You can certainly still receive long-term care, but it won’t be covered by this insurance.
Examples
Still a little unclear? Maybe some examples will help.
Example 1
Let’s meet Mary, a 72-year-old woman insured by Medicare. Mary recently had hip replacement surgery and will need physical and occupational therapy. Mary decides to go to The Enclave, a skilled nursing and rehabilitation facility that accepts Medicare. Mary’s doctor refers her to The Enclave for physical and occupational therapy, and Mary spends two weeks as an inpatient. Mary’s Medicare pays for her stay at The Enclave.
Example 2
Now let’s meet Harry, an 88-year-old man with Alzheimer’s in need of 24/7 long-term care. Harry is also covered by Medicare, but because he hasn’t been referred by a doctor and hasn’t had a qualifying hospital stay, Medicare will not cover his care. How could Harry qualify? If Harry’s doctor decides that he needs daily skilled care given by a skilled nursing team, then the skilled nursing services will be covered, but not the daily activities of living such as assistance with eating or bathing.
Quite often, the decision-making process to go to a skilled nursing facility or receive long-term care is short. We hope this guide will help you in that decision-making process and that this guide will also help those who are planning ahead.
In addition to this guide, it’s important to talk with your case manager and the skilled nursing facility about what insurances they accept and what payment options they offer. Even if you meet all the requirements for your long-term care to be covered, you might realize the facility doesn’t accept this insurance.
At the end of the day, take the time to talk with your case manager, doctor, and skilled nursing facilities to make the best decision for you and your loved ones.
Resources:
Medicare.gov
LongTermCare.gov
