• Mary Sizemore

When Does Medicare Pay for Long-Term Care?

As long-term care insurance specialists, we are often asked if Medicare covers long-term care services. Many people are still under the assumption that Medicare provides a benefit for home care or a skilled nursing facility on a on-going basis. However, Medicare doesn’t cover long-term care (also called custodial care), if that's the only care that is needed.


As you are aware, most long-term care is custodial care. Custodial care helps your client with their activities of daily living. For example, bathing and dressing. These are personal needs that can be done without professional training. Your client pays 100% for non-covered services, including most long-term care.


To better assist you in educating your clients, below are the situations when Medicare will pay, for how long and how much. Your client must have Part A and days left in their benefit period to use the following:


Skilled Nursing Facility (SNF) following a hospitalization

Medicare will help pay for a short stay in a skilled nursing facility if all of the following conditions are met:

  • A qualifying hospital admission usually with an inpatient stay of at least three days

  • Admission to a Medicare-certified nursing facility within 30 of that inpatient hospital stay

  • Needed services include skilled care, such as skilled nursing services, physical therapy, or other types of therapy

If these conditions are met, Original Medicare will pay a portion of the costs for up to 100 days for each benefit period as follows:

  • For the first 20 days, Medicare pays 100 percent of the cost.

  • For days 21 through 100, client pays a daily copayment, which is $185.50 as of 2021 and $194.50 in 2022, and Medicare pays any balance.

  • Medicare does not pay costs for days in a skilled nursing facility after day 100.

Medically Necessary Treatment for Illness or Injury

There is no limit on how long your client can receive any of these services as long as they remain medically necessary, and a doctor reorders them every 60 days. There also is no requirement for their condition to improve, or for improvement to be expected

Medicare pays for the following services when their doctor prescribes them as medically necessary to treat an illness or injury:

  • Part-time or intermittent skilled nursing care (not custodial care) (see guidelines above for SNF)

  • Physical therapy, occupational therapy, and speech-language pathology provided by a Medicare-certified home health agency.

  • Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding their disease

  • Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, Medicare pays 80 percent of approved amount and your client pays 20 percent.


For more information on long-term care insurance, please contact one of our marketing specialists at 1-800-945-1953

60 views0 comments