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Medicare and Planning for Long Term Care



We love to plan for many things across our lifetime, but long term care is generally not on that to do list or something that most individuals enjoy thinking about! Although I often recommend being present and in the moment, I also recommend taking time to do a little advanced care planning for the future. Most people at some point across their lifetime will require some type of care support and ensuring that you have a documented plan in place in alignment with your express wishes is important. It is also important to understand options for care and to be able to make some informed decisions about what you may and may not want alone with having a full understanding of what is a covered and non covered expense.


There are many types of care situations as one grows older. Assisted living is one option for convalescent or custodial care support that is often needed by many individual as they age. In an assisted living environment they provide hands on assistance with a number of areas including - medication administration including insulin, laundry, housekeeping, meals, and support for transfers, bathing, dressing, and general custodial aspects of daily living. It is often a surprise for many that Medicare does not cover general assisted living costs as Medicare does not cover any long term custodial care, meaning assistance with aspects of daily living such as dressing, bathing, or toileting. Most of the care needed for individuals and provided in assisted living is across these areas and not a covered expense. Assisted living is therefore generally either covered by Long Term Care Insurance or privately paid. But there are some assisted living costs that Medicare under part A may cover for physical therapy, speech therapy, occupational therapy and even skilled nursing visits for specific episodes of care. However, one cannot receive long term skilled nursing care at an assisted living facility as this is beyond their scope of practice.


Medicare Part A may cover skilled nursing care in some rehab and Skilled nursing home settings for an episode of care. In order to qualify the individual must have a hospital-related medical condition that is being treated for at least a 3-day inpatient status hospital stay or a condition that started while receiving care in the skilled nursing facility (SNF) for a hospital-related medical condition. Medicare Part A will only pay for these services for up to 100 days per benefit period. Days 1 - 20: $0 copayment unless you are in a Medicare Advantage Plan, as you may be charged copayments during the first 20 days in this case. Days 21 - 100: A $200 copayment each day, After day 100: You pay all costs. A Medicare benefit period begins the day a person is admitted as an inpatient in a hospital or SNF. Observation status does not count towards this. The benefit period ends when you haven't received any inpatient hospital care (or up to 100 days of skilled care in a SNF) for 60 days in a row.


Medicare Part A can help cover skilled nursing care in certain conditions for a limited time if you have Part A, have days left to use as a part of your Medicare benefit period and you have a qualifying hospital stay. Your physician and care team will also need to evaluate and make a recommendation that you need daily skilled care for the specific episode of care at a skilled nursing facility (SNF) as certified by Medicare.


So what happens if you cannot afford assisted living private pay, do not have long term care insurance, or need care support outside of medicare qualifying stays?


There are several paths to take in this regarding depending upon a variety of factors. Reach out today for a care management consult so that you can learn more and we can advise on potential care paths.


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