Learn how Original Medicare & Medicare Advantage relate to nursing home services, non-medical elder care services, and related at-home treatment options.
As people age, they tend to need much more care. Many people assume that Medicare entirely covers long-term care for older Americans who need it. They may be surprised to learn that this is often not the case.
For a better picture of what Medicare does and does not cover, here is a breakdown of how Original Medicare and Medicare Advantage relate to nursing home services, non-medical elder care services, and related at-home treatment options.
It’s important to start by making a distinction between custodial care and skilled nursing care. Both fall under the umbrella of long-term care, but they are two separate kinds of care with different coverage under Medicare.
Custodial care refers to non-medical care that someone without medical licenses or training can provide. This kind of care is typically meant to help someone with basic personal care and activities of daily living, like eating, dressing, and bathing. Custodial care services are often provided by nurse’s aides, but other non-medical professionals can also provide these services.
Skilled nursing care, by contrast, can only be provided by (or at least supervised by) trained and licensed medical professionals. Those who need medical care services, like nursing or rehabilitation, rather than simply help with daily activities require skilled nursing care. This care will generally be ordered by a doctor and provided by physical therapists and nurses.
Various parts of Medicare may cover long-term skilled care. In general, Medicare Part A covers care received in a skilled nursing home facility for up to 100 days. During that time, the person must be receiving skilled care that is necessary for their recovery. There are some additional stipulations for Medicare Part A to cover skilled nursing facility (SNF) care:
During each benefit period, the Original Medicare recipient pays no coinsurance per day for the first 20 days of an eligible stay in an SNF. Starting in 2023, the program will pay up to $200 coinsurance per day for days 21 to 100. In other words, Original Medicare will only cover skilled nursing care under quite limited circumstances and only on a short-term basis.
Coverage for skilled nursing facilities under Medicare Advantage plans is the same from an actuarial standpoint, but the benefits and copays will vary depending on the plan.
Both Medicare Advantage and Original Medicare may cover some at-home treatment services if a doctor certifies that such care is medically necessary and that the individual is unable to leave their home.
Skilled nursing facilities are not typically what people interested in long-term care are looking for. These individuals are often in need of custodial care, the kind of care offered by most standard nursing homes. Nursing homes help residents with activities of daily living and assist them with their personal needs in a safe, friendly environment. Medicare does not cover these non-medical elder care services provided by nursing homes, however.
The list of nursing home-related services Medicare does not cover also includes:
Custodial care Medicare coverage is limited only to instances when the individual also needs skilled care. So, the answer to the question “does Medicare cover nursing homes?” is no. Nursing home care generally won’t be covered by Medicare.
Coverage for nursing home care may be different under a Medicare Advantage plan, though. Because Medicare Advantage plans are provided by private health insurance companies, they provide varying levels of coverage. It’s not standard for Medicare Advantage plans to cover nursing home care, but there are some exceptions. There are special Medicare Advantage plans geared towards nursing home benefits. Your Medicare advisor can walk you through different carrier options to help you find the one that meets your needs.
In summary, neither long-term custodial care nor long-term skilled care is covered under Original Medicare. Medicare Advantage plans have more flexibility to offer long-term care coverage, but this coverage is often still minimal.
Those who need assistance paying for long-term care may need to look for other options, such as an assisted living loan or long-term care insurance. You may also want to ask about dual eligibility for Medicare and Medicaid to cover long-term health expenses; these programs vary by state, so it’s best to get an advisor’s insight first.
When you have questions about your Medicare benefits, our skilled, licensed advisors can help you make sense of your options. Connect with one of our advisors online or by calling or texting (888) 443-5336 (TTY: 711) so we can help you prepare for your long-term health needs.