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.

Long-term care issues critical in national heath care debate

by Alvin Loewenberg, President/CEO of Morningside Ministries

Some would argue the country’s health care system is in a state of crisis. There are countless issues involved in health care reform, and unfortunately, we are attacking the industry’s illnesses with band-aids. We need to look at our ailing health care system from a holistic perspective, one that goes beyond the hospital and acute care settings. When we discuss health care reform, it’s absurd to talk about it without including long-term care in the dialogue.

By 2030, nearly 71.5 million people in the United States will be over the age of 65, which is approximately double the current number of older Americans, according to the Department of Health and Human Services Administration on Aging. In addition, more than 40 million Americans are disabled, many of whom require long-term care. Here in Texas, we have one of the fastest growing elderly populations, with significant growth in San Antonio and the Hill Country.

Aging affects everyone, but too often it is portrayed as something negative, when in reality it means people are living happily and often doing great things. Growing older can and should be a glorious and rewarding experience, just as any other stage of life.

But many people are not equipped financially to pay for a good quality of life as they age.

With baby-boomers aging, the country is just beginning to see the effects of a fast-growing older population in which many do not have the ability to pay for their age-related needs. We have a Medicaid system that is going broke. Medicare, as most people are unaware, is not a funding source for long-term care. Medicare pays for short-term care – up to 20 days of rehabilitation or a portion of nursing care up to 100 days. Private long-term care insurance is unaffordable for many Americans, and, thus it doesn’t provide a secure source of funding for a majority of people.

We need to make a commitment to funding services and resources for long-term care. Long-term care is more than nursing homes. It involves community services, companions skilled nursing care, residential living and in-home care, among many other disciplines. All too often the needs of older adults go far beyond their ability to pay. On many occasions, the services simply are not available, even if there are unlimited personal funds to cover them.

Many older adults continue to live at home as they age, and they need money to pay for things like transportation, meals, house cleaning and household modifications such as handrails for safety and ramps for easier access.

Ninety percent of all older adults are cared for at home by family members, which can take a personal and financial toll on caregivers. Many caregivers have to stop working, but they still have other family to care for. There are few resources for assisting caregivers.

Funding more long-term care programs and services is an investment in our economy and our future, as the healthcare industry generates significant job growth and economic impact. For example, the Texas nursing home industry currently has an $11.3 billion economic impact on the State, according to a 2006 Texas Medicaid Nursing Facility Cost Report compiled by the Texas Health & Human Services Commission. The same report indicates that nursing home spending on Medicaid residents generates a $6.7 billion economic impact in Texas.

The Texas Legislature began the dialogue in the 2009 session, forming a long-term care task force comprised of four legislators and two citizens who will begin studying the issues involved in long-term care, and it will be important for each of us to stay informed and participate in the conversation.

Overhauling the U.S. healthcare system will take new ideas and sacrifice, entrepreneurial innovation and the fortitude to make tough decisions if change is to be expected. But, that’s nothing new for Americans. We are a country built on change and improvement.