Medicare is a federal program that pays certain healthcare expenses incurred by patients who are 65 or older. It also pays those expenses for patients of any age who suffer from a qualifying disability.
Medicare pays a fixed rate for most medical services, including doctor visits and hospital admissions, if those services are meant to help a patient recover from a short-term health problem. Medicare will also pay for certain services, such as physical therapy, that are designed to improve, rather than cure, a patient’s condition.
Tip: For basic information about how Medicare works and what it covers, see Medicare and You.
Long-term care services
The likelihood that a patient will improve because of the medical treatment, as well as the short-term nature of the treatment, are the keys to Medicare coverage. If the purpose of a service is to help a patient cope with a condition that is unlikely to improve, Medicare will probably not pay for that service.
With only a few exceptions, Medicare does not pay for:
- services that a patient will need for an extended period of time that are unlikely to improve the patient’s condition,
- custodial care, such as a nursing home, or
Personal care services include helping a patient engage in the activities of daily living, including bathing, eating, dressing, and moving. Medicare generally does not cover those services whether they are provided by a caregiver who visits or lives with the patient or by an assisted living facility.
There are limited exceptions that allow patients to receive skilled care outside of a doctor’s office or hospital. Under the conditions discussed below, Medicare will pay for short-term skilled nursing care and for care services that your doctor certifies to be medically necessary to treat a medical condition.
Skilled Nursing Care
Medicare does cover a portion of the expense incurred by eligible patients who receive skilled nursing services after a hospital stay. The payment covers a short stay in a skilled nursing facility, a visiting nurse, or a stay in a hospice, provided that certain conditions are met.
To be eligible, a patient must have been hospitalized for at least three days and the services must begin within 30 days after discharge from the hospital. Medicare pays those services in full for the first 20 days and pays for a portion of the services for the next 80 days. Subject to a limited exception for “medically necessary care services,” Medicare will no longer pay for nursing services after a total of 100 days.
Medically Necessary Care Services
Medicare will pay for certain care services if your doctor certifies that they are medically necessary to treat an illness or injury. Those include:
- part-time skilled nursing care,
- physical therapy, occupational therapy, and speech therapy provided by a Medicare-certified home health agency,
- social services that help you access follow-up care or understand or cope with your medical condition, and
- durable medical equipment, such as wheelchairs and walkers (Medicare pays only 80 percent of those expenses).
The key to Medicare’s coverage of those services is your doctor’s certification that they are medically necessary to treat your condition. Your doctor must reorder those services every 60 days to assure that Medicare will continue to pay for them. Keep in mind that your doctor must expect the treatment to result in an improvement of your condition.
While the difference between long-term treatment and long-term personal care is not always clear, it is crucial to Medicare’s decision whether to cover the cost of skilled care. As a general rule, skilled care that is provided by a nurse or therapist is more likely to be covered than unskilled care that helps a patient with the activities of daily living.
Payment for Long-Term Care
While the federal Medicare program generally does not pay for long-term care, other options exist for seniors who lack the financial ability to pay for their own long-term care. Coverage for long-term care services, including the cost of assisted living facilities, nursing homes, and at-home care services, may be available through state Medicaid programs. Medicaid is generally available to persons over the age of 65 who meet certain financial eligibility requirements. While those requirements vary from state to state, Medicaid benefits are primarily intended to help people who have a limited income and few assets.
Veterans may be able to receive benefits that will help pay for long-term care if they lack the financial ability to pay for those services without assistance. Seniors who have long-term care insurance or certain kinds of life insurance coverage may also be able to rely on their insurance benefits to help finance the cost of long-term care.