Medicare is a Federal program designed to cover health care for people age 65 and older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant.) It only covers medically necessary care and focuses on medical acute care (doctor visits and hospital stays) or short-term services for conditions expected to improve.
Generally, Medicare does not pay for most long-term care. Medicare does not pay for personal or custodial care (help with Activities of Daily Living), which is the greatest part of long-term care services.
Medicare will help pay for a limited skilled nursing facility stay, hospice care or home health care if you meet certain conditions, which are described below. Medicare will pay for care in a skilled nursing home when:
- you have had a recent prior hospital stay of at least three days,
- you are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay, and
- you need skilled care such as skilled nursing services and/or physical or other types of therapy.
If all these conditions are met, Medicare pays a portion of your costs for up to 100 days. For the first 20 days, Medicare pays 100 percent of your skilled nursing facility costs. For days 21-100, you pay your own expenses up to $128/day (as of 2008) and Medicare pays the balance, if any. You pay 100 percent of costs for each day of a skilled nursing facility stay after day 100.
Medicare payments for home health care are limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy and speech-language pathology that are ordered by your doctor and provided by a Medicare-certified home health agency. It also includes medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services. Unlike nursing home services, there is no co-pay for home health. There is also no limit on the duration of service as long as services continue to be medically necessary and your doctor requests or reorders these services at least every 60 days. Hospice care is covered for people with a terminal illness, generally individuals who are not expected to live more than six months. Services include drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice provider, and other services not otherwise covered by Medicare (such as grief counseling). Hospice care is usually provided in your home (which may include a nursing home if that is where you live) or in a hospice care facility. However, Medicare does cover some short-term hospital and inpatient respite care ¾ care provided to a hospice patient to allow the usual caregiver to rest.
