Medicare: Coverage in a Skilled Nursing Facility
Jeannine LeCompte, Compliance Research Specialist
Many people presume that Medicare covers all long-term care, such as residing in a nursing home. This incorrect assumption can lead to misunderstandings about payment, and it is worthwhile for sector personnel and the public alike to be aware of what is, and what is not, covered by Medicare.
First, it is important to understand that Medicare does not pay for residential care for people who are disabled or who otherwise cannot care for themselves. In addition, Medicare does not cover “assisted living” (typically thought of as “retirement homes”), adult daycare, or custodial care (assistance with eating, bathing, and dressing).
Medicare does pay for skilled nursing care in a skilled nursing care facility—but only after a three-day hospital stay, and it only pays in full for the first twenty days. Thereafter, it will pay $170.50 per day (2019 figures) for the next 80 days, after which it will stop completely.
Medicare will also pay for home healthcare, when the recipient is homebound by an illness or injury. This means that Medicare will pay for nurses or therapists to provide a maximum of 28 hours of care per week.
Finally, Medicare will cover hospice care, when the patient has been diagnosed with a terminal illness, and has six months or less to live.
This summary makes it clear that for many people, the only option for long-term care coverage is the private purchase of insurance to cover eventualities such as extended home care, assisted living, and nursing home care.
Obviously, this is not viable for everyone, and if an individual’s income or assets are too low—and the definition of “too low” varies from state to state—they might qualify for Medicaid, which will cover most long-term care costs. Some Medicaid programs will require participants to make a small co-payment or pay a small premium.
Some people will qualify for both Medicare and Medicaid programs, in which case most of their health costs should be covered.
