What About Medicare?

There is a great deal of confusion about Medicare and Medicaid.

Medicare is the federally funded health insurance program primarily designed for older individuals (i.e. those over age 65). There are some limited long term care benefits that can be available under Medicare. In general, if you are enrolled in the traditional Medicare plan, and you’ve had a hospital stay of at least three days, and then you are admitted into a skilled nursing facility (often for rehabilitation or skilled nursing care), Medicare may pay for awhile. (If you are a Medicare Managed Care Plan beneficiary, a three day hospital stay may not be required to qualify.)

If you qualify, traditional Medicare may pay for the full cost of the nursing home stay for the first 20 days and can continue to pay the cost of the nursing home stay for the next 80 days, but with a deductible that’s $133.50 per day. Some Medicare supplemental insurance policies will pay the cost of that deductible. For Medicare Managed Care Plan enrollees, there is no deductible for days 21 through 100, as long as the strict qualifying rules continue to be met. So, in the best case scenario, the traditional Medicare or the Medicare Managed Care Plan may pay up to 100 days for each “spell of illness.” In order to qualify for this 100 days of coverage, however, the nursing home resident must be receiving daily “skilled care” and generally must continue to “improve.” (Note: Once the Medicare  and Managed Care beneficiary has not received a Medicare coverage level of care for 60 consecutive days, the beneficiary may again be eligible for the 100 days of skilled nursing coverage for the next spell of illness.)

While it’s never possible to predict at the outset how long Medicare will cover the rehabilitation in the nursing home, from our experience, it usually falls far short of the 100 day maximum.  If the nursing home resident will not benefit from therapy or skilled care and just needs to live in a nursing home for the custodial care, Medicare will pay nothing.  Even if Medicare does cover the 100 day period, what then? What happens after the 100 days of coverage have been used?

At that point, in either case you’re back to one of the other alternatives:  long term care insurance, paying the bills with your own assets, or qualifying for Medicaid.

Continue to more information on Medicaid.