Long Term Care and Medicare, Medicaid, and More

(Administration on Aging) A number of public programs, including Medicare and Medicaid, may help pay for some long-term care services under certain circumstances. However, each program has specific rules about what services are covered, how long you can receive benefits, whether or not you qualify for benefits, and how much you have to pay in out-of-pocket costs. To accurately plan for your long-term care needs, it is very important to know the facts about what may or may not be covered, and to stay current on program changes.

Medicare

Medicare only covers medically necessary care and focuses on medical acute care, such as doctor visits, drugs, and hospital stays. Medicare coverage also focuses on short-term services for conditions that are expected to improve, such as physical therapy to help you regain your function after a fall or stroke.  (In January of 2013 a lawsuit (Jimmo v. Sebelius) regarding the Medicare Improvement Standard was settled.  The Settlement may result in changes to this requirement.)

Eligibility

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 leastthree 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,Medicare pays 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 the Medicare 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.

Hospice care

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 a Medicare-approved hospice provider, and other services that Medicare does not otherwise cover, such as grief counseling. You may receivehospice 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 for caregiver respite.

Download or order the consumer handbook Medicare & You 2013 to learn more about what Medicare does and does not cover.

Veterans Affairs Benefits

The Department of Veterans Affairs (VA) pays for long-term care services for service-related disabilities and for certain other eligible veterans, as well as other health programs such as nursing home care and at-home care for aging veterans with long-term care needs.

The VA also pays for veterans who do not have service-related disabilities, but who are unable to pay for the cost of necessary care. Co-pays may apply depending on the veteran’s income level.

The VA has two more programs to help veterans stay in their homes:

  • The Housebound Aid and Attendance Allowance Program. This program provides cash to eligible veterans with disabilities and their surviving spouses to purchase home and community-based long-term care services such as personal care assistance andhomemaker services. The cash is a supplement to the eligible veteran’s pension benefits
  • A Veteran Directed Home and Community Based Services program (VD-HCBS). This program was developed in 2008 for eligible veterans of any age. The program provides veterans with a flexible budget to purchase services. Counseling and other supports for veterans are provided by the Aging Network in partnership with the Veterans Administration

Visit the Department of Veterans Affairs to view available programs and services or download a Veterans Benefits fact sheet. You can call the VA at 800-827-1000 to obtain information about services available in your area.

Other State Programs

Many states have programs to pay for home and community-based long-term care services for older adults, generally 60 and older, and their families.  States often draw on funds from county, state and federal sources such as the Older Americans Act.  The focus of these programs is to help older adults remain in the community as independently as possible.  States administer these services through state and local agency networks known as the Aging Network, and include:

  • Nutrition programs such as home-delivered meals for homebound elderly or meals served in community settings
  • Transportation services
  • Health promotion services to help prevent disease or manage chronic illnesses
  • Personal care assistance and help with household chores and shopping
  • Legal assistance and services that protect the rights of older persons such as the long-term careombudsman program
  • Family caregiver services and supports including time off from their responsibility, called respite care

While the financial eligibility criteria for these programs differ by state and by program, they are generally targeted for low-income, frail seniors over age 60, minority older adults, and seniors living in rural areas. Specific funds are often set aside for Native American older adults.

Local agencies, called Area Agencies on Aging (AAAs), work with State Units on Aging (SUAs) to plan and develop service and support programs based on the needs of older adults and families. More information on how to connect with your local Area Agency on Aging is available on theAdministration for Community Living website.

There are several databases available to you to locate services in your state:

Aging and Disability Resource Centers (ADRCs)

Where available, each state in the map links to a long-term care resource database maintained by that state for its ADRC. These centers serve as single points of entry into the long-term supports and services system for older adults and people with disabilities.

Eldercare Locator

The Eldercare Locator provides information and links to resources that enable older persons to live independently in their communities. This public service website links to state and local Area Agencies on Aging and community-based organizations that serve older adults and their caregivers.

Centers for Independent Living (CILs)

CILs provide access to resources for people with disabilities that empower individuals to live independently in their communities. Independent Living Research Utilization (ILRU) provides a national database of centers for independent living, and statewide independent living councils. It is updated weekly.

Citation

http://longtermcare.gov/medicare-medicaid-more/

Administration on Aging