Does Medicare Cover Long Term Care Expenses?

Medicare was not designed to cover ongoing long term care services. It  s the federal medical insurance program for people age 65 or older, and disabled persons of any age receiving Social Security benefits for not less than 24 months. It was designed to pay some of the costs of certain health care services in order to provide recipients access to a basic level of health care. The majority of care provided in the U.S. today in connection with chronic long term illnesses or conditions is personal or custodial care.

Like most health care insurance, Medicare does not pay for custodial care. Medicare only pays for services that are considered “medically necessary” according to Medicare guidelines. This might include a skilled nursing facility and home health care for a period of time as part of treatment of an injury or acute illness, but not on an ongoing basis. One example would be rehabilitation services in a skilled nursing facility as described below.

  • Following a hospitalization of at least three days for treatment of a hip fracture, Medicare would pay up to the first 20 days of a stay in a Medicare-certified skilled nursing facility as long as the individual requires skilled services such as nursing and physical therapy prescribed by a physician.
  • Days 21 through 100 may be covered if the individual continues to meet Medicare criteria for skilled care. Each of these days would have a co-payment determined yearly by the Centers for Medicare & Medicaid Services (CMS). Medigap policies may cover the daily co-payment amount.
  • After 100 days, Medicare will pay nothing for these services. Also, if it is determined that the individual no longer meets Medicare criteria for skilled care prior to 100 days, services will be discontinued. When an individual is receiving Medicare-covered services, regular eligibility reviews are performed to determine ongoing eligibility.

Medigap (also known as Medicare Supplement Insurance) includes 12 standard (with a few state specific differences) plans labeled A-L which are defined by Medicare but offered through private insurers. They are intended to cover some of the “gaps” in Medicare. These gaps include the costs of coinsurance, co-payments, and deductibles. Some of the plans offer benefits not offered through Medicare, such as emergency travel coverage outside of the U.S. Like Medicare, Medigap does not cover ongoing long term care services1.

1“2009 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare,” Centeres for Medicare & Medicaid (CMS) and National Association of Insurance Commissioners (NAIC), September 2008.