TONI SAYS: I thought Medicare covered long-term care

By Toni King

Dear Toni:

Recently in your Medicare column, you discussed services that are not covered by Original Medicare such as dental, vision, long-term care, and other items. I thought Medicare covered long-term care but was wrong, because my mother suffered a severe stroke, and her rehab facility notified me that Medicare is not paying for my mother’s care. Beginning next week, for her to receive care from this facility, it will have to be private pay, or she will have to go home.

I need help understanding this confusing Medicare system. What is the difference between rehab/skilled nursing care and long-term care? I thought they were both the same!! Thanks for your help. Sue from Little Rock, Ark.

Hi Sue:

Trying to understand the rules of Medicare when a loved one has a severe illness and requires both medical and custodial care is very frustrating. People are living longer today and want to control the quality of care, especially when they need assistance as their health begins to change. So I will try to explain what long-term care is in simple terms.

Page 56 of the 2024 Medicare & You handbook, under “Paying for long- term care” discusses how important it is to plan now to maintain your independence and receive the proper care in the setting you desire. Medicare only pays for medically necessary skilled nursing facility care or for home health care if you meet certain conditions. Skilled nursing has 100 days of benefit with days 1-20 having a $0 copay per day and days 21-100 with a specified copay per day. If you cannot qualify or do not meet Medicare’s qualification for skilled nursing, you will pay 100% of the cost out of your pocket. This is when having purchased a long-term care policy becomes essential.

Long-term care includes medical and non-medical care for those who have a chronic illness or disability. They may need help with activities of daily living such as bathing, dressing, eating, transferring, continence, ability to use the bathroom or have cognitive impairment. At least 70% of people over 65 will need long-term care services at some point. Long-term care can be provided at home, in an assisted living facility, personal care home, or nursing home. Long-term care can be very costly. The average cost ranges from $54,000 a year for a 1 bedroom assisted living facility to $94,900 for an average nursing home. Original Medicare does not pay for these services.

Below are some options to pay for long-term care:

1) Purchase a long-term care insurance policy. The younger you are when you purchase a long-term care policy, the lower the premiums will be. Many wait too long and qualifying is not easy because of health issues that keep one from meeting the underwriting requirements. Begin searching for a plan while you are younger and in good health.

2) Purchase a life insurance policy with a long-term care provision. Many life policies have such a provision so that you can receive a certain amount of your life policy’s face amount.

3) Research what your qualifications are for your specific state’s Medicaid. Verify what must be “spent down” to qualify.

4) Aid and Attendance benefits with the VA can help Veterans and spouses with long-term care issues.

5) Dedicate personal resources such as savings, IRA, 401K to help pay for long-term care needs.

Americans are concerned about a chronic illness being their biggest retirement expense if not planned for properly. Remember, with Medicare it’s what you don’t know that WILL hurt you! Email your LTC or Medicare questions to [email protected] or call Toni Says at 832/519-8664 for additional help. Monday, March 4, and March 11 Toni is “live” on discussing Medicare with Bill Horan from Nassau Community College in New York.