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Medicare has limits

| Jul 18, 2019 | Long-Term Care Planning

Putting off planning for financing a nursing home or other assisted living can lead to unwanted surprises. Counting on Medicare may have unexpected consequences because it has restrictions and does not pay for long-term nursing home care and other care except in limited circumstances.

Medicare pays for medical expenses in a nursing home, assisted living facility or a person’s home. But it does not cover the costs of staying in those facilities or custodial care.

Medicare does pay for short-term stays in skilled nursing facilities which may include nursing homes. These short-term stays are usually associated with specialized nursing care and rehabilitation after being in a hospital. For this coverage, the patient must have been a formally admitted patient and stayed in the hospital for at least three days if the patient was enrolled in the original Medicare program.

Spending time under observation in a hospital, however, does not meet the requirements for SNF coverage. This hospital care is also paid for through Medicare Part B which may raise its cost.

The three-day rule has exceptions. Its restrictions usually do not govern patients enrolled in HMOs, PPOs or other Medicare advantage plans. Also, the rule covers treatment at a skilled nursing facility. Medicare will pay for care under different guidelines at a rehabilitation hospital or another type of facility for ongoing care.

Medicare also pays, for those who qualify, short-term care in a skilled nursing facility. It covers the complete costs for the first 20 days. The patient must pay a daily copay, $164.50 in 2017, for days 21 through 100. For the time over 100 days, the patient is responsible for the full cost unless they have Medigap or other insurance.

Without Medicare, families may have to rely on their own resources or purchase insurance policies. Medicaid may pay for coverage if the patient meets Michigan’s requirements, but this may have financial consequences. An attorney can help provide options on paying for care and protecting assets.

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