Will Medicare pay for my care?

If you ever need nursing home care, will Medicare pay for it? Well, maybe, but maybe not.

Contrary to what many people believe, their Medicare coverage will not pay for their long-term care needs. And chances are good that you will need some assistance during your lifetime. According to a recent Business Week article, 65% of people over the age of 75 need long-term care and, with an aging population, that number will continue to climb.

Generally, Medicare will pay for care in a skilled nursing community if it is medically necessary and you have met certain conditions that they have set out. Medicare will cover a short-term nursing stay for rehabilitation from an injury or illness, but only following a three-night hospital stay. A rehabilitation stay is covered in full for up to 20 days. After 20 days, if the need for skilled care continues, the resident will be required to pay a co-insurance, which is the amount uncovered by Medicare from days 21 – 100. Many Medicare supplements pay the co-insurance amount.

Medicare does not, however, provide coverage for services in assisted living communities. Assistance with the activities of daily living, such as bathing, dressing, grooming, medication management and using the bathroom are not considered “skilled” services and are not covered under Medicare. Assisted living communities typically only accept private pay and long-term care insurance.

So if Medicare will not pay for your needs, will Medicaid? Once again, the answer is maybe. Medicaid is a joint state and federal government program that pays for long-term care services for older adults with low incomes and limited assets. But, to qualify, you must exhaust all your assets and virtually all of your income. Medicaid recipients must have less than $2,000 in assets. To qualify for long-term care nursing home Medicaid, you must meet “medical necessity,” which basically states that you require 24-hour nursing care supervision. Because the number of applications for Medicaid has increased exponentially over the past few years, states are increasingly making it more difficult to receive Medicaid funding.

According to the U. S. Health Care Financing Administration, about 40% of long-term care bills are paid for by Medicaid and 18% are paid by Medicare. That leaves 42% of all long-term care bills to individuals and families to pay out of their own pocket or to insurers to pay.