Knowing Your Medicare Coverage And Limitations!



Medicare does not cover any type of long-term care, whether in nursing homes, assisted living facilities or people’s own homes. Of course, it covers medical services in these settings, but not the cost of staying in any long-term care facilities or the cost of any “custodial” care — that is, help with the everyday tasks of life, such as dressing, feeding, going to the bathroom — except for very limited circumstances when a person receives home health services through a Medicare-approved agency.

Medicare does, however, provide coverage for short-term stays in skilled nursing facilities — which are, very often, nursing homes. You would go to a skilled nursing facility (SNF) for specialized nursing care and rehabilitation work after spending time in the hospital. But, if you’re enrolled in the original Medicare program, to get coverage for an SNF you must have spent at least three days in the hospital as a formally admitted inpatient.

This condition is extremely important. The hospital can formally admit you as an inpatient — or it can place you into “observation status.” In both cases, you are lying in a hospital bed, eating hospital food, and being attended to by hospital doctors and nurses. But any days spent under observation do not count toward the three-day inpatient requirement that you need for Medicare coverage in an SNF. Also, your hospital stay will be paid for under Part B, not Part A, which could increase your costs. When you enter the hospital, you must be told whether you’re being properly admitted or are under observation. If the latter, you may want to appeal to your doctor to see if you can be transferred to inpatient status.

However, note that there are two exceptions to the three-day rule:

  • It usually doesn’t apply to people enrolled in Medicare Advantage plans (such as HMOs or PPOs) — so best to check with your plan.
  • It affects only coverage in a skilled nursing facility. If you’re discharged from the hospital to another kind of facility for specific ongoing care, such as a rehabilitation hospital, Medicare provides coverage under different rules.

If you qualify for short-term Medicare coverage in a skilled nursing facility, Medicare pays 100 percent of the cost (room, meals, nursing care) for the first 20 days. For days 21 through 100, you pay a daily copay ($164.50 in 2017). If you remain in the SNF longer than 100 days, you’re responsible for the full cost, unless you have additional insurance (such as Medigap) that covers it.

As Medicare doesn’t pay anything toward the considerable cost of staying in a nursing home or other facility for long-term care, who does? Some people have long-term care insurance that would pay according to the terms of their policies. Otherwise, you must pay out of pocket until your own resources are used up. At that point, Medicaid — the state-run health care program that provides virtually free coverage to low-income people who qualify — often begins to pay the bills. Eligibility depends on your state’s rules. For additional information, you can contact me from the links below.




To take the next step, You can contact me from my info listed below or you can fill on this form for a call back,

Sandy Essex,
CLTC Long Term Care Planning Advisor
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