Doesn’t Medicare, Medicaid/MediCal, or another public program help pay for Long-Term care?

There are a number of public programs that provide help paying for long-term care services. Each program has specific rules for what types of services it covers, how long one can receive services, eligibility for coverage, and, in some cases, cost sharing. For example, some programs, such as the Older Americans Act, focus on home- and community-based services, while the Medicare program only pays for some short-term nursing home stays or home health care. The following section provides information on some of the major public programs that may help pay for long-term care services.

Medicare is a Federal program designed to cover health care for people age 65 and older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant.) It only covers medically necessary care and focuses on medical acute care (doctor visits and hospital stays) or short-term services for conditions expected to improve.

Generally, Medicare does not pay for most long-term care. Medicare does not pay for personal or custodial care (help with Activities of Daily Living), which is the greatest part of long-term care services. Medicare will help pay for a limited skilled nursing facility stay, hospice care or home health care if you meet certain conditions, which are described below.

Medicare will pay for care in a skilled nursing facility when:

•you have had a recent prior hospital stay of at least three days,
•you are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay, and
•you need skilled care such as skilled nursing services and/or physical or other types of therapy.
If all these conditions are met, Medicare pays a portion of your costs for up to 100 days. For the first 20 days, Medicare pays 100 percent of your skilled nursing facility costs. For days 21-100, you pay your own expenses up to $133.50/day (as of 2009) and Medicare pays the balance, if any. You pay 100 percent of costs for each day of a skilled nursing facility stay after day 100.

Medicare payments for home health care are limited to medically necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy and speech-language pathology that are ordered by your doctor and provided by a Medicare-certified home health agency. It also includes medical social services, medical supplies, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Unlike nursing home services, there is no co-pay for home health, but for durable medical equipment you pay 20% of the Medicare approved amount. There is no limit on the duration of service as long as services continue to be medically necessary and your doctor requests or reorders these services at least every 60 days.

Hospice care is covered for people with a terminal illness, generally individuals who are not expected to live more than six months. Services include drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice provider, and other services not otherwise covered by Medicare (such as grief counseling). Hospice care is usually provided in your home (which may include a nursing home if that is where you live) or in a hospice care facility. Medicare does cover some short-term hospital and inpatient respite care to a hospice patient to allow the usual caregiver to rest.

Medicaid is a joint Federal and state government program that helps pay medical costs for some people with limited incomes and resources. People with Medicaid may get coverage for services such as nursing home and home health care, if they meet the eligibility requirements for Medicaid. Who is eligible and what services are covered vary from state to state. Most often, eligibility is based on your income and personal resources, but for coverage of long-term care services, you must also meet certain health or functional criteria to be eligible. The best source for that information is your State Medical Assistance office, whose phone number can be found at the Medicare Helpful Contacts [offsite] search page. Your state Medicaid agency's website also has more information.

Sometimes you must spend down (or use up) your personal resources (assets) before you qualify for Medicaid. You may want to get more detailed information from your State Medical Assistance office or an attorney before spending down your resources.

A Brief History of Medicaid

The Medicaid program was enacted by Congress in 1965 in the same legislation that created the Medicare program. Medicaid is a state-administered program overseen at the Federal level by the Centers for Medicare & Medicaid Services (CMS). Specific program limits are set through a combination of Federal requirements and options, giving states flexibility in the design of their programs. As a result, standards and rules vary considerably from state to state.

Medicaid was originally designed to provide health care to poor families, children, the aged, and the disabled. Over time, the number of people served, as well as the cost of serving those people, has increased dramatically. A large part of that growth has been the number of people receiving long-term care services and the cost of providing those services.

The most common types of long-term care that Medicaid pays for are institutional care and home- and community-based service.

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