Nursing facility, nursing home, hospice
What Medicare provides and what comes from your own pocket
Nobody likes to think about needing a nursing home or hospice. I think it frightens most of us; I know it scares the heck out of me. But often it’s part of what we all face if we’re lucky enough to grow old or unlucky enough to have a terminal illness.
Unfortunately, as healthcare in the United States is an overpriced and dysfunctional mess, we have to work within the system we have. So unless you’re a billionaire, read on.
What exactly do we have?
Medicare
As with everything else about Medicare, we’re faced with confusing language and layers of rules at a time when we’re the most vulnerable - physically, emotionally, and often financially. These are difficult decisions, so planning before you need help is crucial whatever your circumstances.
Medicare covers some nursing services, but there are definitions and conditions that you have to meet. Both you and anyone handling your medical needs must be aware of these. Having the opportunity to plan is better than not.
This is a good opportunity to make sure you have an up-to-date healthcare-proxy. You should also designate someone with whom Medicare, Social Security, and any other insurance provider can discuss your account, benefits, and your personal medical information. For Medicare, you can take care of this in the Medicare section of the Social Security website or on the Medicare website. And if you don’t already have online Social Security and Medicare accounts this is the time to set them up as it makes things easier.
It’s also a good idea to give someone your Power of Attorney and a Living Will. But note that the Social Security Administration doesn’t recognize the ordinary Power of Attorney for handling and receiving someone else’s Social Security benefits. You have to apply for that separately. See the Social Security website for information.
An overall good source of information about these documents is the National Institute on Aging.
Let’s start with the basic definitions.
Custodial care
Non-medical care that helps you with Activities of Daily Living, also known as ALDs. These include bathing, using the toilet, cooking, cleaning, and other necessary functions.
You can get custodial care, which is often provided by a health aide, while living in a nursing home, as part of a post-hospital stay in a rehabilitation facility, or in your own home.
Custodial care on its own isn’t medical care no matter how badly its needed and Medicare doesn’t cover it.
Nursing home
A residence, usually permanent, for people who need custodial care 24/7.
Skilled nursing facility
A temporary residence for patients undergoing medically-necessary rehabilitation treatment following a stay in the hospital.
Assisted living
An assisted living community allows you living independence and some privacy, but it also has staff to help with daily custodial care and medical staff should you need it. These can be stand alone communities or they can be on the grounds of a nursing home or rehabilitation facility.
Hospice
A facility or other living situation that provides care for people with a terminal illness at the end of their lives.
Home care
Just like other custodial care, this non-medical support can be provided in your own home.
Who covers what and when?
The bad news is that Medicare doesn't cover custodial care regardless of where it’s delivered if it's the only care you need and/or how badly it’s needed. That includes nursing homes, assisted living, and home care.
The good news is that there is one situation when Medicare will cover custodial care, and that’s in a skilled nursing facility when it follows a qualifying stay in the hospital.
According to Medicare, a qualifying hospital stay is
an inpatent hospital-stay of at least three consecutive days, not including the day you’re discharged. In addition, you also must also
be enrolled in Medicare Part A (hospital insurance)
have your doctor prescribe the skilled nursing care
have it at Medicare-certified facility
start the care within 30 days of being discharged from the hospital
But this is not a blank check and there are limits to the length of stay and amount of coverage.
If you enter the skilled nursing facility within 30 days of your qualifying hospital-stay Medicare will pay the full cost for up to 20 days.
After the first 20 days you’re responsible for part of the cost. If you don’t have supplemental insurance, you’ll pay $204 a day in 2024 for days 21 - 100.
If you still need care after 100 days in the facility you’re responsible for the full charge.
Benefit periods
If you’re able to leave the skilled nursing facility within the 100-day limit, you can’t begin a new benefit period until you’re out of the hospital or other facility for 60 consecutive days. At that point, if you meet all the same requirements, you can start another benefit period. There is no limit to the number of benefit periods you can have.
Medigap/Medicare supplement insurance
Medicare supplement insurance (aka Medigap) is private insurance only available with Traditional Medicare Parts A and B. Depending on your policy, you can get help with some or all of the skilled nursing facility costs that are not covered under Medicare. But be aware that not every Medigap policy covers it. Medigap Plans C, D, F, G, K, L, M, and N provide coverage for co-insurance costs, but Plans A and B don’t. It’s important to know this before you purchase a Medigap insurance policy
After 100 days, if you still need care check Medicare’s home health coverage to see if you qualify.
Hospice care
If the time comes for hospice care, Medicare offers coverage as follows under Medicare Part A, the hospitlization portion of Traditional Medicare. Note that hospice care refers to a process of palliative care within a facility (nursing home, a Medicare-certified hospice facility, a nursing home, a hospital) or at home.
Your doctor and the hospice doctor must certify in writing that you’re terminally ill with no more than six months to live.
You agree in writing to accept only palliative care rather than care to treat your illness.
If you’ve met the requirements, hospice doesn’t cost you anything, but there can be some costs associated with it.
A copayment of up to $5 for out-patient prescription drugs for pain and other symptoms of your terminal illness. Some of the drugs may be covered under Medicare Part D.
You may have to pay for room and board if you live in a nursing home and choose to have hospice care there.
Medicare Advantage
MA has the same rules as Medicare. For specifics about your coverage, check your contract and contact your insurance agent or provider.
Long-term care insurance
“Long-term care (LTC) insurance provides care in a nursing-home care, home-health care, and personal or adult daycare for individuals age 65 or older or with a chronic or disabling condition that needs constant supervision. LTC insurance offers more flexibility and options than many public assistance programs, such as Medicaid.”
“There are also some alternatives to LTC insurance that have come on the market in recent years” due to the high cost of LTC insurance.
Medicaid
If you’ve outlived your money, you may get some assistance through Medicaid. As Medicaid is a state administered program, each state has its own requirements.
Medicare in the news
Verywellhealth.com Difficulty paying your Medicare premiums? Help is available.
American Prospect: the Great Medicare Advantage Marketing Scam
Kaiser Family Foundation: The New Help for Medicare Beneficiaries with High Drug Costs That Few Seem to Know About
Lever News: Private Equity comes for your health insurance
The Washington Post How your in-network health coverage can vanish before you know it
NPR Hospitals are fighting a Medicare payment fix that would save tax dollars
CMS Beginning in 2025 you can pay out of pocket drug costs in installments
CNBC: Florida nurse convicted of $200 million in Medicare fraud scheme
AARP Millions of People Pay Medicare Late-Enrollment Penalties for Life after Missing Key Deadlines
Lever News Americans Paid $11 Billion To Make Drugs You Can’t Afford