Basics of Long Term Care Insurance
Isn't long term care services covered by Medicare or other health insurance?
Medicare: Medicare does NOT pay for most long term care services. Individuals should not rely on Medicare to meet their long term care service needs. Medicare does not pay for custodial care when that is the only kind of care needed. Skilled nursing facility care is covered by Medicare but only on a very limited basis.
In order to obtain Medicare coverage of a skilled nursing facility stay, the following five conditions must be met:
- Your condition must require daily skilled care which, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
- You must have been in a hospital at least three days in a row (not counting the day of discharge) before you are admitted to a certified skilled nursing facility.
- You must be admitted to the facility within a short time (generally within 30 days) after you leave the hospital.
- You must have received treatment in a hospital for the condition for which you are receiving skilled nursing care.
- You must receive certification from a medical professional that you need skilled nursing care or skilled rehabilitation services on a daily basis.
If the skilled nursing facility stay continuously meets all of the above conditions, Medicare will provide benefits for up to 100 days of skilled care in a skilled nursing facility during a benefit period. In 2011, for the first twenty days of care, all covered services are fully paid by Medicare. For the next 80 days of care, Medicare requires a copayment (the amount you must pay) of up to $141.50 per day. Medicare does not cover custodial care.
If you need skilled health care in your home for the treatment of an illness or injury, Medicare can pay for home health services furnished by a home health agency. You do not need a prior hospital stay to qualify for home health care. Medicare pays for home health visits only if all four of the following conditions are met:
- The care you need includes intermittent skilled nursing care, physical therapy, or speech language pathology.
- You are confined to your home.
- You are under the care of a physician who determines you need home health care and sets up a plan for you to receive care at home.
- The home health agency providing services participates in Medicare.
Once all four of these conditions are met, Medicare will pay for covered services as long as they are medically reasonable and necessary. Coverage is provided for the services of skilled nurses, home health aides, medical social workers and different kinds of therapists. The services may be provided either on a part-time or intermittent basis, not full-time.
Medicare pays the full cost of medically necessary home health visits by a Medicare-approved home health agency. You do not have to pay a deductible or coinsurance for services; however, if you need durable medical equipment, you are responsible for a 20% coinsurance payment for the equipment.
Medicare will NOT pay for full-time nursing care at home, drugs, meals delivered to your home, and homemaker services that are primarily to assist you in meeting personal care or housekeeping needs.
More information on Medicare and changes to the deductibles and copayments under Medicare is available on the web site of the Centers for Medicare and Medicaid Services at http://cms.hhs.gov.
Medicare supplement insurance: Is designed to fill in some of the major gaps in Medicare coverage, but IT DOES NOT COVER MOST LONG TERM CARE SERVICES.
Other private health insurance that you might already have covers mainly acute conditions and probably does NOT cover custodial care.
Medicaid: A governmental program for low-income individuals and families, is currently the major source of funding for long term care services. In order to qualify for Medicaid coverage, persons must meet certain income and asset tests. Because of the high cost of nursing home care, more than half of those who enter nursing homes privately paying for their care reach this level in less than a year. In New York State in 2011, if only one spouse needs nursing home care, the married couple is allowed to keep a home, a car and assets up to $109,560. A single person who requires such care may have resources up to $13,800 and still qualify for Medicaid. The Partnership for Long Term Care’s web site provides more information on Medicaid Eligibility at http://www.nyspltc.org.
In 1993, New York State initiated the Partnership for Long Term Care. Under the Program, if you purchase a Partnership-approved long term care policy and meet certain other requirements, you will be able to obtain Medicaid coverage, after the benefits under the long term care policy are exhausted. Qualification will be based on your income and you will be permitted to retain some or all of your assets (depending on the policy purchased) (See the NYS Partnership for Long Term Care section on page 7 and the Partnership’s official site at http://www.nyspltc.org)
Updated 04/04/2011
