Long Term Care Benefits

Medicare and Long Term Care

Medicare generally does not provide coverage for long-term care or custodial care in a facility. Long-term care or custodial care refers to assistance with activities of daily living (ADLs) such as bathing, dressing, eating, toileting, and transferring. 

These services are typically required by individuals who have chronic illnesses, disabilities, or conditions that make it difficult for them to perform these activities on their own.

Medicare primarily covers medically necessary services that are considered skilled care and are provided by trained medical professionals. This includes services such as hospital care, doctor visits, skilled nursing care, home health care, and some hospice care.

Medicare Part A might cover a limited stay in a skilled nursing facility (SNF) under specific conditions, but only for a short period of time and under strict eligibility criteria:

1. Qualifications for SNF Coverage: To qualify for Medicare coverage in a skilled nursing facility, a beneficiary must have been hospitalized for at least three consecutive days as an inpatient, and the care needed in the skilled nursing facility must be related to the hospitalization and require skilled nursing or rehabilitation services.

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3. Coverage Limitations: Medicare Part A covers up to 100 days in a skilled nursing facility, but full coverage is generally limited to the first 20 days. For days 21 to 100, there may be a daily coinsurance amount that the beneficiary is responsible for.

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5. Medical Necessity: The care received in the skilled nursing facility must be deemed medically necessary and provided by licensed medical professionals.

It's important to note that Medicare does not cover custodial care or long-term care in facilities such as nursing homes or assisted living facilities if the primary need for care is assistance with activities of daily living rather than skilled medical care. 

If an individual requires custodial care or long-term care services, they would need to explore other options for coverage, such as Medicaid (which is a state and federally funded program for low-income individuals) or private long-term care insurance.

In summary, while Medicare does offer limited coverage for skilled care in a skilled nursing facility, it does not cover custodial care or long-term care in most facilities. Individuals who anticipate needing long-term care should consider exploring other insurance options and planning for their future care needs accordingly.