What is Medicare?

Medicare is health insurance from the federal government for Americans ages 65 and older. Since Medicare is health insurance, it does not cover long-term care. Medicare is very confusing and the rules seem to change all the time.

Medicare has four parts:

  • Part A is often called “hospital insurance” and covers part of the costs for care in a hospital and rehab facility.
  • Part B is called “medical insurance” and helps cover doctor bills and outpatient care.
  • Part C is commonly referred to as “Medicare Advantage” and consists of Part A and Part B coverage from a Medicare approved private sector provider.
  • Part D provides some coverage for Prescription Drugs. You pay for Part D unless you are in a Part C/Medicare Advantage plan that covers prescription drugs.

We already know that the vast majority of long-term care is unskilled care or custodial care – so it is NOT covered by Medicare. In fact, the Medicare website states:

“Medicare doesn’t cover custodial care if it is the only kind of care you need.”

To make things confusing, Medicare can cover part of the cost for a limited stay in a nursing home. Medicare can cover up to 100 days in a Nursing Home if:

1) The patient first spends at least three days in a hospital

2) The patient improves every consecutive day in the Nursing Home for the next 100 days.

The first day the patient does not improve Medicare ends the claim for the year. This is because the first day the patient does not improve they turn into a “custodial” or “unskilled” patient and Medicare does not cover that. Typically, Medicare only pays for about 21 days a year for Nursing Home care. On day 22 the patient is still in need of care, but Medicare has ended the claim because the patient did not improve on day 21.

Please note that it is very likely that someone will still need extensive help once Medicare stops paying for Nursing Home care.

How much can Medicare pay for covered nursing home care?

Medicare pays 100% of the cost for the first 20 days of a covered nursing home stay. The patient then pays a co-pay for the remaining days until they reach 100 days in the facility which is the maximum possible benefit for care; then Medicare ends the claim and the patient either pays the entire daily bill for the care themselves or they go home.

Complete information on Medicare can be found at www.medicare.gov.