What the programs cover, and what they don’t
by Tamara Lytle
What role does the federal government play in assisting Americans in need of long-term care? The answers, which lie primarily within two programs — Medicare and Medicaid — may may surprise you. Here is a breakdown of the services they do and don’t offer.
Does Medicare cover the costs of long-term care?
No. This is a common misconception. As a reminder, Medicare is strictly a health insurance program that covers costs related to illnesses and injuries (and, to some extent, their prevention). As such, it will help pay for up to 100 days of rehabilitation or skilled nursing care after a major health issue, based on a doctor’s recommendation. But longer stays, such as a permanent move into a nursing home, are not covered.
What about Medicare Advantage?
You can check to see if there’s a Medicare Advantage plan in your area that offers limited caregiving assistance. You may be able to find one that provides meals or pays for installation of grab bars, says Howard Gleckman, senior fellow at the Urban Institute. A small number of so-called special needs plans offer some in-home support services. If a Medicare Advantage plan has a five-star rating, you may switch to it outside of the annual enrollment period.
What about Medicaid?
Medicaid does pay for long-term nursing-home care, but only for people with very low income and modest savings who can no longer handle basic daily tasks like dressing or feeding themselves. Gleckman says a good rule of thumb is that if you have less than $750 in income per month and less than $2,000 in financial assets (not counting a home), you likely qualify for Medicaid.
This excludes a large number of people who draw Social Security, given that the average monthly benefit check is more than $1,600. Remember that Medicaid is meant to help just the very poor. Most middle-class people and even low-income people do not qualify, although sometimes people use up their savings and spend so much of their income on care that they do become eligible.
But also note that the Medicaid program is a partnership between the federal government and each state, meaning criteria for who qualifies and what benefits are available can vary based on where you live. Some states provide some benefits to people with low incomes who are over the basic qualification limit, but they are expected to pay for part of the care.
What about care services at home?
It’s important to distinguish between medical care and daily care needs like bathing, eating, moving about and such.
As noted, Medicare will pay for assistance like physical therapy or skilled nursing care, whether in a facility for short periods or at home, where there is no specific time limit, while a patient is recovering from an illness or injury. A supplemental Medigap policy may help with some at-home medical care costs, Gleckman says.
“But for people who are unable to care for themselves at home and don’t have a family member to help manage their daily activities, Medicare doesn’t fill that gap,” says Tricia Neuman, head of the Kaiser Family Foundation Program on Medicare Policy.
Medicaid is another matter. If you meet its stringent requirements, some recipients can get coverage for aides to help with activities like dressing and toileting, says Sara Rosenbaum, a law professor at the George Washington University Milken Institute School of Public Health. But even those benefits only go so far. “Medicaid is not going to provide anything remotely like 12 hours of help,” Gleckman notes. And again, benefits — and funding levels — vary by state. Oregon and Minnesota, in particular, have robust programs to help people live at home or in the community instead of in nursing homes.
Veterans should check with the U.S. Department of Veterans Affairs, which has some programs for those needing ongoing care, including a foster care program through which veterans live with families who can help them. For broader background on long-term care, visit longtermcare.acl.gov. The Area Agencies on Aging are a good clearinghouse for information on nonprofits or other community resources. Go to eldercare.acl.gov.
What if I just need a break as a caregiver?
Some state Medicaid programs pay for adult day programs that offer medical services. And some Medicare Advantage plans are beginning to offer coverage for adult day care and other breaks for family members, says Robert Saunders, senior research director for health care transformation at the Duke-Margolis Center for Health Policy. “There are more options now than there used to be.”
In end-of-life situations, Medicare will pay for respite care in hospice. That palliative care coverage is available when someone is considered to be in the final six months of life.
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