LTC Question Related to Medicare

jmarkk1

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What's the best way to understand LTC as it relates to Medicare coverage? How does it go beyond what Medicare pays, etc.?
or as it relates to MAPD or Supp coverage?
 
The simplest statement is to basically say that Medicare does not really cover ANY long term care needs...whether you have a supplement or not. Medicare might cover up to 100 days of nursing home/rehab following a hospitalization, but good luck getting coverage for more than 30-40 days on average without showing "progress" to Medicare guidelines.

If you are unfortunate enough to ONLY have a MAPD plan and not a Med Sup, then the coverage is even worse with all the co-pays that kick in sooner.

If a doctor writes a prescription to have a nurse come out and do wound care or check your sugar levels.....that is a Medicare visit. If you need on going help with your ADL's then you are on your own if you have no LTC insurance.

Now if you are broke...there is Medicaid.
 
What's the best way to understand LTC as it relates to Medicare coverage? How does it go beyond what Medicare pays, etc.?
or as it relates to MAPD or Supp coverage?


Medicare pays for rehabilitative care.
LTCi pays for custodial care (aka "personal care").

nadm
 
The "Skilled Nursing" benefit is not nursing home coverage. As others have posted, Medicare will not pay for one hour in a nursing home if someone is there because they can no longer care for themselves.

Skilled Nursing, a good example is a broken hip, is for recovery for things like a broken hip. A lot of hospitals do not provide the kind of physical therapy required to recover from a broken hip. However, they may contract with a nursing home to provide those services.

Because it is provided in a nursing home and Medicare pays for it a lot of people assume that Medicare pays if someone has to go to a nursing home. Nothing could be farther from the truth.
 
In order to have a converstion with Medicare regarding coverage for LTC services, one must meet 2 specific criteria:

1) The care required must be skilled care (Skilled care is generally short-term care, lasting less than 6 weeks. A broken hip or a knee replacement for example requires skilled, rehabilitative care
2) Care must be received within 30 days of being released from a minimum 3-day hospital stay.

If one meets that criteria, here is what Medicare pays:
Days 1-20 100% of all charges (less any deductibles)
Days 20-100 Medicare pays everything with the exception of a co-pay, which this year is $140/day
After day 100......... Nothing

And, if anytime during that 100 days, the patient no longer required skilled care, Medicare will no longer pay.

Now, if the patient has a Medicare Sup, that policy will pick up
the deductibles along with the 80-day co-pay.

In no scenario (as stated previously) will Medicare pay for 20 minutes of custodial care by itself.
 
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