What is Long Term Care?
- Using the toilet
- Transferring (to or from bed or chair)
- Caring for incontinence
Other common long-term care services and supports are assistance with everyday tasks, sometimes called Instrumental Activities of Daily Living (IADLs) including:
- Managing money
- Taking medication
- Preparing and cleaning up after meals
- Shopping for groceries or clothes
- Using the telephone or other communication devices
- Caring for pets
- Responding to emergency alerts such as fire alarms
What Causes a Long Term Care Need?
- The older you are, the more likely you will need long-term care
- Women outlive men by about five years on average, so they are more likely to live at home alone when they are older
- Having an accident or chronic illness that causes a disability is another reason for needing long-term care
- Between ages 40 and 50, on average, eight percent of people have a disability that could require long-term care services
- 69 percent of people age 90 or more have a disability
- Chronic conditions such as diabetes and high blood pressure make you more likely to need care
- Your family history such as whether your parents or grandparents had chronic conditions, may increase your likelihood
- Poor diet and exercise habits increase your chances of needing long-term care
- If you live alone, you’re more likely to need paid care than if you’re married, or single, and living with a partner
The facts may surprise you.
Consumer surveys reveal common misunderstandings about which public programs pay for long-term care services. It is important to clearly understand what is and isn’t covered.
- Only pays for long-term care if you require skilled services or rehabilitative care:
- In a nursing home for a maximum of 100 days, however, the average Medicare covered stay is much shorter (22 days).
- At home if you are also receiving skilled home health or other skilled in-home services. Generally, long-term care services are provided only for a short period of time.
- Does not pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services
- You will have to pay for long-term care services that are not covered by a public or private insurance program
- Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level and you must meet minimum state eligibility requirements
- Such requirements are based on the amount of assistance you need with ADL
- Other federal programs such as the Older Americans Actand the Department of Veterans Affairs pay for long-term care services, but only for specific populations and in certain circumstances
- Most employer-sponsored or private health insurance, including health insurance plans, cover only the same kinds of limited services as Medicare
- If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care
Does Medicare Pay For Long Term Care?
Medicare pays for health care for people age 65 years and older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).
Long-term Care Services – Skilled Nursing
Medicare does not pay the largest part of long-term care services or personal care—such as help with bathing, or for supervision often called custodial care. Medicare will help pay for a short stay in a skilled nursing facility, for hospice care, or for home health care if you meet the following conditions:
- You have had a recent prior hospital stay of at least three days
- You are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay
- You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy
If you meet all these conditions, Medicare will pay for some of your costs for up to 100 days. For the first 20 days, Medicarepays 100 percent of your costs. For days 21 through 100, you pay your own expenses up to $140.00 per day (as of 2013), and Medicare pays any balance. You pay 100 percent of costs for each day you stay in a skilled nursing facility after day 100.
Long-term Care Services – Home and Other Care Services
In addition to skilled nursing facility services, Medicare pays for the following services for a limited time when your doctor says they are medically necessary to treat an illness or injury:
- Part-time or intermittent skilled nursing care
- Physical therapy, occupational therapy, and speech-language pathology that your doctor orders that aMedicare-certified home health agency provides for a limited number of days only
- Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding your disease
- Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, you pay 20 percent of theMedicare approved amount
There is no limit on how long you can receive any of these services as long as they remain medically necessary and your doctor reorders them every 60 days.
Medicare covers hospice care if you have a terminal illness and are not expected to live more than six months. If you qualify for hospice services, Medicare covers drugs to control symptoms of the illness and pain relief, medical and support services from aMedicare-approved hospice provider, and other services thatMedicare does not otherwise cover, such as grief counseling. You may receive hospice care in your home, in a nursing home (if that is where you live), or in a hospice care facility. Medicare also pays for some short-term hospital stays and inpatient care forcaregiver respite.
Download or order the consumer handbook Medicare & You 2013 to learn more about what Medicare does and does not cover.
Medicaid is a joint federal and state government program that helps people with low income and assets pay for some or all of their health care bills. It covers medical care, like doctor visits and hospital costs, long-term care services in nursing homes, and long-term care services provided at home, such as visiting nurses and assistance with personal care. Unlike Medicare,Medicaid does pay for custodial care in nursing homes and at home.
Overall program rules for who can be eligible for Medicaid and what services are covered are based on federal requirements, but states have considerable leeway in how they operate their programs. States are required to cover certain groups of individuals, but have the option to cover additional groups. Similarly, states are required to cover certain services, but have the option of covering additional services if they wish to do so. As a result, eligibility rules and services that are covered vary from state to state.
To be eligible for Medicaid you must meet certain requirements, including having income and assets that do not exceed the levels used by your state. The section on “Medicaid Eligibility”, which you can go to by clicking on the link below, provides more detailed information about how to become eligible for Medicaid.
Once your state determines that you are eligible for Medicaid, the state will make an additional determination of whether you qualify for long-term care services. When determining whether you qualify for long-term care services, most states use a specific number of personal care and other service needs to qualify fornursing home care or home and community-based services. There may be different eligibility requirements for different types of home and community-based services.
Your State Medical Assistance office is the best source for information about how to qualify for Medicaid in your state and if you qualify for long-term care services.