According to a recent report, 70% of U.S. adults who live to age 65 will eventually need long-term care (LTC). In addition, 48% will receive some type of paid medical care over their lifetime.
As you age, you may require more consistent medical attention than you did when you were younger. Often, this requires hiring someone to come to your home on a routine basis to help with your personal care.
While such services can be incredibly helpful, they can also be cost-prohibitive. You may wonder if you can use your benefits of Medicare to help offset those expenses.
Today, we’re sharing everything you need to know about using Medicare to help cover your LTC services.
What Is Long-Term Care?
Before we dive into ways to afford long-term care, let’s take a step back. What is LTC in the first place and what does it entail?
In short, LTC includes a range of health services provided to meet an individual’s healthcare or personal care needs. The service period can be short-term or long-term. The goal of LTC is to help people live independently and safely, even when they can no longer perform basic, everyday activities on their own.
There are many different ways someone could receive LTC. The exact environment will depend on their needs, as well as the availability of their designated caregivers. Typically, LTC occurs at home, with unpaid family members and friends offering the requisite support.
Other times, it can be provided in a facility, such as a nursing home. In addition, LTC can also be considered a local resource, offered through adult daycare programs, for instance.
Types of Services Provided
The most common type of LTC is personal care. In these situations, the caretaker is responsible for helping the patient perform daily activities, such as:
- Using the restroom
- Moving around the home
- Preparing and eating meals
- Household chores
If LTC is provided as a city or community resource, it may also include services. Examples can include:
- Dining services
- Transportation services
- Games, activities, and other recreational services
These services may be free to participants, or the provider may charge a fee.
When long-term healthcare is required, it usually occurs as a result of a severe, ongoing health condition or a disability. While a sudden condition such as a heart attack or stroke can necessitate LTC, it usually develops gradually over time as the individual ages.
Home healthcare can vary in terms of scope and scale. Medical professionals who provide long-term support in this way may be required to perform the following tasks:
- Helping patients recover from surgery, accident, or injury
- Physical therapy
- Speech therapy
- Occupational therapy
- Prescription management and administration
Can You Apply the Benefits of Medicare to LTC?
If you’re already on Medicare insurance, you may wonder: Will my plan cover any portion of my long-term care? The answer to this question can be a little tricky, so let’s break it down.
Medicare does not cover certain types of long-term care but it does cover home healthcare.
Here’s what this means.
Your plan is unlikely to help pay for costs associated with a long-term care facility, such as:
- A nursing home
- An assisted living facility
- Any other residential setting outside your personal residence
Yet, this absence of financial support doesn’t change your need for these services. Let’s take a look at a few of the ways you can make this process more affordable.
Financing LTC Outside the Home
If you require long-term care outside of your home and need assistance, there are resources that can help. Here are the ones to consider as you begin this journey.
As a state and federal program, Medicaid provides health coverage to individuals on a limited income. Designated as the country’s largest financer of LTC services, this coverage will help you pay for nursing home care. While the specific benefits can vary from one state to the next, all states would have a Medicaid program in place that’s specifically designed to cover LTC, both at home and in a nursing home setting.
Wondering if you meet your state’s eligibility criteria? All you have to do is call your local Medicaid office. They’ll be able to assess your situation and determine if you qualify for this type of aid.
Understanding Medicaid nursing home benefits can be complicated, so it’s important to reach out if you have questions. Most of the time, Medicaid will pay 100% of nursing home costs as long as individuals meet the eligibility requirements. Under this program, you will usually have three options to choose from, which include:
- Skilled nursing services: Short-term or long-term care related to medical issues
- Rehabilitation services: Short-term care following an illness, injury, or surgery
- Long-term care: 24/7 care related to a physical or mental condition
If you use Medicaid to cover these services, the plan will pay a fixed daily rate to the nursing home. Examples of services that this rate typically covers include:
- General costs of nursing care
- Room and board
- Social services
- Meal services
- Prescriptions and over-the-counter medications
- Special rehabilitation needs
- Personal hygiene and toiletry items
Note that if you require extras beyond these basics, such as a private room, special meals, or electronics, you may be required to pay for those items out of pocket.
Local Senior Centers
In lieu of Medicaid, you can also reach out to your local senior center if you need help paying for LTC. Often, these centers will have programs in place designed to help with a variety of needs, including:
- Shopping assistance
Depending on the size of your center, you may also be able to secure case management services there. You can reach out to your local Chamber of Commerce to find the one closest to you.
Faith-based charities and organizations often provide support for seniors in need of LTC. If you require everyday services, financial assistance, or any other type of help, they may be able to provide it. If they do not have the resources on hand, they can usually refer you to other, local organizations that do.
The Benefits of Medicare for Home HealthCare
While Medicare does not cover most LTC services, there is one exception: home healthcare. You can find details about this support under the Home Health Benefits section of your Medicare plan. If you’re interested in going this route, here are a few of the benefits you can expect.
Paid Nursing Services
If individuals require a skilled aide to work inside their homes, Medicare will usually pay for this service in full. This includes both skilled nursing and skilled therapy services.
While this can be an ideal solution, it’s important to understand one caveat: Medicare will not pay for an aide if you require personal care only and do not need skilled care. You must be able to show that the services you (or a loved one) require include any of the below:
- Part-time/intermittent care from skilled nurses
- Part-time/intermittent home health aide care
- Physical therapy
- Speech-language pathology services
- Occupational therapy
- Medical social services
- Injectable osteoporosis drugs (women)
- Medical supplies for home use
- Durable medical equipment
Note that the part-time home health aide care only qualifies if you are also getting other skilled services at the same time, such as nursing or therapy.
It can be difficult to coordinate home healthcare services on your own. Thankfully, your Medicare plan can also help with this step.
As long as you work with a Medicare-certified home health agency, that agency should be able to coordinate all of the services that your doctor has ordered for you. This includes establishing a care plan that clearly outlines the type of support you need as well as the frequency at which you need it.
This can relieve some of the stress from your shoulders and allow you to focus more intently on your personal health and well-being. You can also reach out to a Medicare insurance agent to learn more about your plan and what types of services it covers.
Who Can Apply?
At this point, you may be asking yourself, Am I eligible to apply for this type of LTC coverage?
The first step in determining eligibility is to understand the specific type of Medicare plan you are on. Home healthcare is only covered for participants who have Medicare Part A and/or Part B.
Yet, that’s not all of the requirements. To be eligible, you must also meet all of the following conditions:
- Be homebound (certified by your physician)
- Be under the care of a physician
- Be receiving services under a care plan created and reviewed by a physician
- Require (per physician’s certifying orders) one or more of the following services:
- Intermittent skilled nursing care (beyond drawing blood)
- Physical therapy, occupational therapy, or speech-language pathology
In this instance, being homebound means that you have difficulty leaving your home unassisted, due to an illness or injury. For instance, you may need to use a wheelchair, walker, or cane when you leave. Or, you may rely on special transportation or assistance from another individual.
While you can leave the home for specific medical treatment or make infrequent trips for reasons such as religious services, you should be mostly at home to receive this benefit. The only exception is adult daycare, which you can still attend.
Types of Services Covered
In terms of the types of services covered, Medicare will only kick in to help cover those costs if your physician can show that the services meet three criteria:
In addition, the physician must also be able to verify that the amount of services required is reasonable for your condition, as well as the frequency and time period they’re provided. They should also show that the services are too complex for you to do on your own, and require the presence of a qualified therapist to complete.
Duration of Care
Sometimes, home healthcare is required only on a short-term basis. Other times, a care plan can be set up on a maintenance basis, designed to help you control your medical condition. Medicare can cover both types of plans, but you must be able to detail which type of plan you’re establishing.
Your physician can add these details to your plan, describing which of the following three scenarios applies to your case:
- Your condition should improve in a reasonable and predictable timeframe
- You require a skilled therapist to create a maintenance program for your condition
- You require a skilled therapist to perform maintenance therapy for your condition
What if you require more than part-time care? If that is the case, then you will not be eligible for the Medicare Home Health Benefit.
What LTC Home Health Services Are Not Covered by Medicare?
While Medicare can greatly offset the financial burden of paying for home healthcare on your own, there are limits to this type of coverage. Most of the time, your Medicare plan will not cover the following services:
- Around-the-clock, 24/7 home daycare
- Meal delivery to your home
- Custodial care or personal care
- Homemaker services unrelated to your care plan
In this case, custodial care refers to activities required for daily living, such as dressing, bathing, or using the bathroom. While this may be included (and paid for) in your skilled nursing care, it is not applicable if it is the only care you need.
Likewise, your Medicare plan will not pay for any type of housemaker services, including laundry, cleaning, and shopping, unless they are directly related to your care plan.
Understand More About Your Medicare Benefits Today
As you can see, understanding all of your Medicare benefits can be an intricate process. While you cannot use your plan to cover out-of-home LTC services, you can apply the benefits of Medicare to help pay for your home healthcare needs.
To learn more about how these programs work and determine if you qualify, we encourage you to sign up for our weekly email newsletter. We’ll send you two short emails per week, filled with relevant content, free tips, downloads, lessons, discounts, and more. Sign up on our website or become a member today to unlock more savings!