Medicare and Medicaid are both government-funded health insurance programs that help seniors and low-income individuals afford nursing home care. It can be confusing to determine whether or not you qualify for coverage, and what services are covered. In this blog post, we will break down Medicare and Medicaid coverage for nursing home care, so that you can make the best decision for your loved one. Does Medicare pay for nursing home? Good question. Let’s find out.
What is Medicare?
Medicare is a health insurance program for seniors and disabled individuals. It is funded by the federal government and provides coverage for doctor visits, hospital stays, and some preventive care services. Medicare does not cover long-term care services, such as nursing home care.
What is Medicaid?
Medicaid is a government-funded health insurance program for low-income individuals and families. It is jointly funded by the federal government and state governments. Medicaid covers a wide range of health care services, including long-term care services such as nursing home care.
Do I Qualify for Medicare Coverage?
If you are 65 years of age or older, you automatically qualify for Medicare coverage. If you are under 65 years of age and have a disability, you may also qualify for Medicare coverage.
Do I Qualify for Medicaid Coverage?
To qualify for Medicaid coverage, you must meet your state’s income and asset eligibility requirements. In general, Medicaid covers individuals and families with incomes below the federal poverty level. However, each state has different income and asset eligibility requirements.
What Services Does Medicare Cover?
Medicare does not cover long-term care services, such as nursing home care. Medicare will pay for a limited number of days of skilled nursing care after a hospital stay, but this coverage is only available if you meet certain criteria. Now that we know answer to: does Medicare pay for nursing home, lets see what may be covered while in care.
Medicare would cover any medical needs that might arise while a person is in a nursing home, such as needing hip surgery after a fall (if surgery were medically necessary).
Additionally, if the care needed was above the level of a nursing home, Medicare might cover it. For example, if a Medicare-enrolled person needed rehabilitation after surgery, Medicare Part A would pay for treatment in a skilled nursing facility (SNF). Treatment in an SNF could include a semi-private room, meals, physical therapy, and more – supposing the patient has enough days left on their benefit period. See everything Medicare Part A covers here.
What Services Does Medicaid Cover?
Medicaid covers a wide range of health care services, including long-term care services such as nursing home care. Each state has different coverage requirements, so it is important to check with your state’s Medicaid office to find out what services are covered in your state. List of things covered:
- Semi-private room
- Food specific to the needs of the resident
- Nursing care
- Activities to promote well-being
- Basic grooming and hygiene services
- Medications
Medicaid doesn’t include any extras (things like a TV, clothing, books or magazines, a private room, etc. – the “non-essentials”). Items or services such as these will be charged to the resident.
Nursing Home Activities
Before looking at what Medicare and Medicaid cover, it’s helpful to review the situations in which they offer their distinct services. One of the most common situations arises when someone gets to a point where it’s difficult or impossible to perform some activities of daily living (ADLs). ADLs are tasks that people must do every day to remain independent, and they include:
- Getting in and out of a bed or a chair
- Walking around (ambulating)
- Using the bathroom
- Brushing teeth or combing hair
- Dressing and undressing
- Feeding oneself
Once a person cannot perform one or more ADLs, they may choose to go to a nursing home. A nursing home is a general term describing a broad category of homes that provide care to residents, but the National Institute on Aging puts it the most succinctly: “A nursing home is a place for people who don’t need to be in a hospital but can’t be cared for at home.”
Generally, nursing homes provide long-term care for people who struggle with ADLs, but they can provide much more. Nursing homes can hire skilled nursing staff or other staff to help accommodate residents with ADLs as well as provide room, board, and recreational events or outings.
Options for Paying
Nursing homes can get costly. If you enter into a nursing home and have to pay for it yourself, there are several options:
“Spending down” resources, then qualifying for Medicaid
Know that if you ever run out of money while in a nursing home, Medicaid coverage will kick in once your resources fall below a level specified by your state’s Medicaid program. Many Medicare beneficiaries who require nursing home care spend their own money until Medicaid coverage begins.
Using life insurance to pay for long-term care
If you have a life insurance policy with living benefits, you may be able to take out your death benefit early and use it to help pay for nursing home expenses, supposing you qualify according to your policy provisions. If you have a permanent policy, you may also be able to borrow from the cash value to help pay for expenses.
Keep in mind, that any money borrowed from a life insurance policy will likely be subtracted from your beneficiary’s inheritance.
Long-term care insurance
You may be able to get a long-term care insurance policy to help pay for your stay in a nursing home. Every policy is different, however, so read the fine print to see exactly what the policy will cover before you fork over your hard-earned money.
Bottom Line
So now that we answered the question “Does Medicare pay for nursing home”, you can now prepare for what is to come. The best way to avoid the high cost of nursing home care is to plan. If you are unable to do this, however, there are several options available to help pay for nursing home care, including Medicaid and long-term care insurance. Do your research and speak with a insurance advisor to find the best option for you.
We are here to help and answer any questions that you may have! Thanks for reading!