Does Medicare Pay for Long-Term Care? — In Plain Words

What long-term care is

Medicare.gov says long-term care — also called “custodial care” or “long-term services and support” — includes medical and non-medical care for people who have a chronic illness or disability. Most long-term care helps with basic personal tasks of everyday life, sometimes called “activities of daily living.” Medicare.gov’s list of examples includes:

• Help with personal care assistance (like dressing, bathing, and using the bathroom)
• Home-delivered meals
• Adult day health care
• Transportation

The ACL page says it this way: long-term care is a range of services and supports you may need to meet your personal care needs. Most long-term care is not medical care. It is assistance with the basic personal tasks of everyday life, sometimes called Activities of Daily Living (ADLs), such as:

• Bathing
• Dressing
• Using the toilet
• Transferring (to or from bed or chair)
• Caring for incontinence
• Eating

The ACL page also lists help with everyday tasks, called Instrumental Activities of Daily Living (IADLs). Its list includes housework, managing money, taking medication, preparing and cleaning up after meals, shopping for groceries or clothes, using the telephone or other communication devices, caring for pets, and responding to emergency alerts such as fire alarms.

Medicare.gov says you can get non-medical long-term care services at home, in the community, in an assisted living facility, or in a nursing home. Getting care in one of those places does not make Medicare pay for it.

What Medicare does not pay for

Medicare.gov states: “Long-term care is different from skilled nursing facility care. Since most long-term care is non-medical, Medicare and most health insurance don’t pay for long-term care services, including care in a nursing home or in the community.”

The ACL page states the same line in its own words: Medicare “does not pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services.”

Medicare.gov also states: “You pay all costs for non-covered services, including most long-term care.” The ACL page states: “You will have to pay for long-term care services that are not covered by a public or private insurance program.”

Medicare.gov advises: “It’s important to start planning for non-medical long-term care now to maintain your independence and make sure you get the care you may need, in the setting you want, now and in the future.” And it adds: if you’re an American Indian or Alaska Native, contact your local Indian health care provider for more information.

The different kind of care Medicare can pay for: skilled care

Medicare.gov’s skilled nursing facility page defines skilled care this way: “Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. It’s health care given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and evaluate your care.”

The ACL page matches that line: Medicare only pays for long-term care if you require skilled services or rehabilitative care. At home, that is if you are also receiving skilled home health or other skilled in-home services. The ACL page adds that, generally, long-term care services are provided only for a short period of time.

Skilled care is not custodial care. Help with bathing, dressing, or eating, on its own, is not skilled care, and Medicare does not pay for it.

The conditions for skilled nursing facility care

Medicare.gov’s skilled nursing facility page says: “You must meet all of these conditions:”

• You have Part A and have days left in your benefit period to use.
• You have a qualifying inpatient hospital stay.
• You enter the skilled nursing facility within a short time (generally 30 days) of leaving the hospital.
• Your doctor or other health care provider has decided that you need daily skilled care (like intravenous fluids/medications or physical therapy). You must get the care from, or under the supervision of, skilled nursing or therapy staff.
• You get these skilled services in a Medicare-certified skilled nursing facility.
• You need skilled services for an ongoing condition that was also treated during your qualifying inpatient hospital stay (even if it wasn’t the reason you were admitted to the hospital), or for a new condition that started while you were getting skilled nursing facility care for the ongoing condition.
• You need skilled nursing or therapy to improve or maintain your current condition, or to prevent or delay it from getting worse.

About the hospital stay, Medicare.gov states that Medicare will only cover care you get in a skilled nursing facility if you first have a qualifying hospital stay. That means a prior inpatient hospital stay of at least 3 days in a row, starting the day you were admitted as an inpatient, but not including the day you leave the hospital.

Medicare.gov also states: “Time you spend at the hospital under observation or in the emergency room before you’re admitted doesn’t count toward the 3-day qualifying inpatient hospital stay, even if you’re there overnight.”

Medicare.gov notes one exception to the 3-day minimum: you may not need it if your doctor participates in an Accountable Care Organization (ACO) that’s approved for a “Skilled Nursing Facility 3-Day Rule Waiver.” Medicare.gov’s advice is: “Always ask your doctor or hospital staff if Medicare will cover your SNF stay.” (SNF is Medicare.gov’s short form for a skilled nursing facility.)

How long skilled care can last

Medicare.gov’s skilled nursing facility page states: “Part A limits SNF coverage to 100 days in each benefit period.” It also states: “Medicare covers certain daily SNF services on a short-term basis.”

The ACL page states the same limit in its own words: Medicare pays in a nursing home “for a maximum of 100 days.”

One hundred days is a limit, not a promise. All of the conditions above must still be met, and the care must still be skilled care.

What Medicaid does

Medicaid is a separate program from Medicare. The facts in this section are the ACL page’s, labeled as such.

The ACL page states: Medicaid “does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level and you must meet minimum state eligibility requirements.” It adds: “Such requirements are based on the amount of assistance you need with ADL.”

Medicare.gov’s long-term care page points the same way: although you’re not eligible for long-term care under Medicare, you may be eligible for it through another program if you meet eligibility requirements in your state, or you can choose to buy private long-term care insurance.

Other payment points the official pages state

• ACL: other federal programs, such as the Older Americans Act and the Department of Veterans Affairs, pay for long-term care services, but only for specific populations and in certain circumstances.
• ACL: like public programs, private sources of payment have their own rules, eligibility requirements, copayments, and premiums for the services they cover.
• ACL: most employer-sponsored or private health insurance covers only the same kinds of limited services as Medicare. If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care.
• ACL: private payment options include long-term care insurance, reverse mortgages, life insurance options, and annuities. This page lists them only because the ACL page lists them. It does not describe or recommend any of them.

This page is general information only. It is not medical advice.

Only Medicare and your state can speak to your own case. This page decides nothing.