If I have Medicare, how can I get help paying for my long term care needs?

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Medicare

Medicare by itself pays for a limited amount of long-term supportive services. Medicare covers up to 100 days of care in a nursing home (skilled nursing facility) after you have spent three days in the hospital and as long as you need skilled care. In some cases, Medicare will cover home health care, but eligibility requirements are strict and Medicare typically approves coverage of only four to ten hours a week of care (it can cover up to 35 hours). Medicare will also pay for hospice care for people who are terminally ill.

Medicare will only pay for care in Medicare-certified skilled nursing facilities or through Medicare-certified home health or hospice agencies. It will never pay for care in a continuing care retirement community (CCRC) or in an assisted living facility (ALF).

If you have a chronic illness or disability and need extensive long-term supportive services, you will probably need to find resources other than Medicare to help pay for these services.

Medicaid

Medicaid may help pay for home health care, nursing home and other long-term care services if you have low income and meet other eligibility requirements.

  1. All states must cover home care services as part of their Medicaid programs for people who are over the age of 65, have a disability or are blind and whose ability to function requires home care (but not a nursing-home level of care). Many states also choose to cover personal care to help with activities of daily living or case management services to connect you with support services not covered by Medicaid, such as housing assistance.
  2. Medicaid will pay for the cost of a stay in a nursing home for people who need a nursing level of care. Medicaid nursing facility coverage includes services such as room and board, case management, skilled nursing care, therapy services and personal care. You must meet your state's income, asset and level-of-care or functional eligibility criteria to qualify for Nursing Facility Medicaid. States determine their own functional eligibility standards, but usually your state will assess your need for help with activities of daily living (for example, toileting, bathing, dressing) and your need for nursing care.
  3. All states have home and community-based service (HCBS) Medicaid waiver programs that help people stay in their homes or community-based settings. When you qualify for a home and community-based service waiver program, Medicaid will cover services that can help you stay at home or in community settings (for example, in an assisted living facility). Such services may include include personal care, homemaker services, case management, assisted living, personal care, skilled nursing care and therapy services. You must meet your state's income, asset and level-of-care or functional eligibility criteria to qualify for home and community-based service Medicaid. States determine their own functional eligibility standards, but usually your state will assess your need for help with activities of daily living (for example, toileting, bathing, dressing) and your need for nursing care.

Veterans Benefits

The Department of Veterans Affairs (VA) provides long-term care services to some eligible veterans through three national programs: VA nursing homes; state veterans' homes; and community nursing homes that work with the VA. Each program has its own eligibility requirements. For help determining which program you may qualify for, contact the VA social worker at your local VA facility.

In addition to nursing home care, the VA also offers other long-term care services in VA facilities and through community centers that work with the VA. VA long-term care services include adult day care services, respite care, home-based care, geriatric evaluations and management, and hospice care. Ask a VA benefits manager at your local VA facility for more information.

Program of All-Inclusive Care for the Elderly (PACE)

PACE is a government program available in certain states to people with Medicare or Medicaid who:

  • are at least 55 years old;
  • live in an area serviced by a PACE program;
  • have been assessed to be frail enough to meet the state's standards for nursing home care; and
  • sign and agree to the PACE enrollment agreements.

If you qualify, PACE will cover all the medical, social and rehabilitative services you need, including items that Medicare does not cover, such as social work services, meals and nursing home care. You will receive all of your health care (Medicare and Medicaid benefits) through the PACE program.

Long Term Care Insurance and State Partnerships for Long Term Care

  • Long-term care insurance from private insurance companies covers some of the costs of long-term care and can help you preserve your assets. It generally covers nursing home care and home care, but only if your needs are substantial enough. Each policy sets a minimum set of health care needs that trigger coverage to begin.
  • Some states have a State Partnership for Long-Term Care. Such a program allows you to purchase a long-term care insurance policy from an insurance company (contracted by the state) and protect some or all of your assets. If, when you ultimately need long-term care, you need additional services beyond what the policy covers, the state will allow you to set aside a portion or all of your assets (depending on the type of policy you have). You can then apply for Medicaid and those assets will not be counted in assessing your eligibility for long-term care benefits.

    Be aware that you are not automatically eligible for Medicaid when you reach the limit of your Long-Term Care Partnership policy. You will still need to meet income and asset guidelines (only the income guidelines if you have a policy that protects all of your assets) to be eligible for Medicaid.

While long-term care insurance and state partnerships for long-term care can limit health care costs for some people, they are not good options for everyone. The insurance can be expensive and premiums can increase substantially as you age. You should not consider a long-term care policy if you have limited income or assets or if paying the premiums would require that you make any lifestyle changes. And if you have Alzheimer's or other serious health problems, you may not be able to buy a policy at any price. Do your research before deciding to purchase a long-term care insurance policy. Read reviews and ratings of the insurance company and make sure that you understand the benefits and rules of the plan.

Paying for Long Term Care Yourself

Many people go without coverage and pay for care themselves. You need to think about how much care may cost over an extended period of time and as you become increasingly frail. Find out about nursing home care costs in your area. Then calculate how much money you would need for a four-year stay. If you can set aside enough to cover four years of residential care, you should consider simply paying for it yourself. Keep in mind that actual costs cannot be predicted. If you have or develop Alzheimer's or other forms of dementia, you may need care for many more years.

Home care often costs much less than residential care. Since people often wish to continue living in their own homes, you may want to research the cost of home and community-based services in your area. Such services, along with home adaptations (like ramps for wheelchair access), may help you stay in your own home.


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Getting Medicaid if you do not need long-term care and have Medicare

Medicare drug coverage in a nursing home

Types of home health care that Medicare will pay for

Types of care that Medicare covers if you elect the hospice benefit

What is Medicaid?

 
LINKS
American Association of Colleges of Nursing (AACN)

Programs of All-inclusive Care for the Elderly (PACE) Directory

State Insurance Department Websites

The Federal Long-Term Care Insurance Program

National Clearinghouse for Long-Term Care Information

American Association of Homes and Services for the Aging (AAHSA)

National Long-Term Care Ombudsman Resource Center

National Directory of Long-Term Care Ombudsmen

 
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