What you need to know about Medicare

Failing To Plan: Why NOT to Rely on Medicare to Cover Nursing Home Expenses

Studies show that most Americans fail to prepare for the costs of long term care because they believe that Medicare or their own health insurance plans will pay the bill. This, however, is not the case. In fact, Medicare was never intended to pay the cost of long term nursing home expenses.

Contrary to popular belief, Medicare also does not cover all medical expenses. Medicare does not pay for routine physicals, eye and hearing exams, dental care, self-administered prescription drugs, and many other medical products and services. Many long term health problems requiring custodial or private nursing care, like Alzheimer’s disease, are also not covered. Medicare does not cover custodial care when it is the only kind of care that a patient needs. Care is considered custodial when it is primarily for the purpose of helping with daily living activities or personal needs that could be provided safely and reasonably by persons without professional skills or training. Much of the care provided to people with chronic, long term illnesses or disabilities in nursing homes is considered custodial care. For example, custodial care includes help with walking, getting in and out of bed, bathing, dressing, eating, and taking medicine. Even if an individual is receiving care from a participating home health agency, Medicare does not cover the stay if the patient needs only custodial care.

Provided a person qualifies, Medicare could help pay for up to 100 days of skilled are in a skilled nursing facility. All covered services for the first 20 days of care are paid by Medicare. All covered services for the next 80 days are also paid by Medicare, except for a daily coinsurance amount paid by the patient. This amount is $128 per day in 2008. If the patient requires more than 100 days of care in a benefit period, they are responsible for all charges beginning with the 101st day.

With regard to qualifying for Medicare covered skilled nursing facility benefits, a person must meet all of the following requirements:

Require daily skilled care that, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis;
Be in the hospital for at least three consecutive days, not including the day of discharge, before entering a skilled nursing facility that is certified by Medicare;
Be admitted to the skilled nursing facility for the same condition for which they were treated in the hospital;
Be admitted to the facility within 30 days of their discharge from the hospital; and,
Be certified by a medical professional as needing skilled nursing or skilled rehabilitation services on a daily basis.

Keep in mind that Medicare will not pay for the nursing home stay if the services required are primarily for personal care or custodial services, such as assistance with walking, getting in and out of bed, eating, dressing, bathing, and taking medicine.