Joel Mekler | Medicare Moments: Misconceptions About Using Medicare to Pay for Long-Term Care | Lifestyles

October is nationally recognized as Long Term Care Planning Awareness Month. Do you have a plan in place?

The month focuses on a range of opportunities and actions older people and their caregivers can take to better understand and prepare for the potential costs of long-term care services in the future. Unfortunately, this is not something that people expect. Statistics show that most people don’t understand the different forms of long-term care, the different ways to pay for it, and most don’t plan for long-term care until a health care crisis hits. hit them.

In my experience as a Medicare counselor, I regularly talk to seniors who are worried about costs at the end of their life. Several families told me that they were taking out reverse mortgages, spending their savings and dipping into their retirement accounts to pay for long-term care.


Long-term care is a range of services and supports that a person may need in the future for personal care. Most long-term care is not medical care but rather assistance with basic daily living tasks, sometimes called activities of daily living (ADL), such as bathing, dressing, going to toilet, transfer and eat. This also includes supervising someone with dementia, such as Alzheimer’s disease.


•Fact: According to, 70% of people over 65 can expect to use some form of long-term care during their lifetime, typically for about three years. This means that there is a good chance that you will need long-term care in the future.

•Fact: By 2050, an estimated 27 million people will need long-term care.

•Fact: One in three people who reach the age of 65 will need nursing home care.

•Fact: Only 35% of Americans report having set aside money to meet their long-term care needs.

•Fact: 78% of seniors who need care receive it from a family member or loved one. Although caregiving may be acceptable for a time, family members usually cannot continue caring for a sick loved one for long. Caring for a sick parent, grandparent or other family member is a significant burden and will put a strain on family members. According to an AP poll of public attitudes about long-term care, 51% of caregivers say the experience has caused stress in their family.

• Fact: The national annual median cost of care ranges from over $108,000 per year for a private room in a nursing home to $20,280 per year for adult day health care services five days a week , according to Genworth Financials 2021 Cost of Care Survey. A semi-private room costs $7,756 per month or $93,075 per year.

•Fact: Medicare and regular health insurance do not cover long-term care. That’s why it’s crucial that you plan for the huge expense of long-term care. While it’s impossible to predict whether or how much you’ll need this care, prevention is far better than cure, especially since Medicare can’t bail you out.

Long-term care is a complex and frightening national issue. It is important to remember that most people have no experience of long-term care until a family member needs care. Then, a family is plunged headlong into a fragmented web of private and public services at a time when immediate and critical care decisions must be made.

Try Googling “am I eligible for Medicaid?” You can spend hours scanning your state’s website or phoning a regional aging agency to determine the difference between Medicaid for nursing homes and home care or if your state has a waiting list for several months for assisted living.

Local resources and services, and the names of each, vary from community to community and challenge searches by family members who do not live in the same community as the person in need of care. Often, only expensive, fee-based options are available to those who are not yet eligible for a dizzying array of public programs once savings and other resources have been exhausted.

It is also important to note that it is the family members, not the person with a disability, who arranges any benefits a person may have and will need to inquire about Medicare, Medicaid, or private insurance. Most are overwhelmed by navigating a maze of arcane terms, definitions, conditions, exclusions and requirements for which they have no knowledge or expertise.

Medicare is a great program. It provides essential health insurance to millions of elderly and disabled people. But, contrary to popular belief, Medicare does not cover long-term care in skilled nursing facilities (often called nursing homes).

At best, Medicare only covers up to 100 days of skilled nursing care per benefit period. To be covered by Medicare, the patient must need and receive daily skilled nursing care and therapy. It is not uncommon for people to be told that they do not meet this standard, even when they do. If someone needs more than 100 days of such care during a benefit period, they will have to pay out of pocket.

In addition, Medicare only covers a stay in an EHPAD if the stay was preceded by hospitalization for at least three consecutive days. This requirement of prior hospitalization is increasingly difficult to satisfy since many hospital stays are now qualified as “ambulatory” observation status, and not hospitalization. This policy further and unfairly limits Medicare benefits for skilled nursing in residential care settings.

If the patient can be cared for at home, Medicare home medical coverage may be available for nursing, therapy, and home health aides as long as the person meets the coverage criteria. These include the general inability to leave home, occasionally or for specific reasons. Medicare won’t pay for custodial care – the help you need to function – if the patient doesn’t need skills.

Many people end up in nursing homes or assisted living facilities not because they are sick or injured, but because their bodies no longer function as they used to and their mobility is limited. That’s where long-term care comes in, and it’s an expense you’ll typically have to meet without Medicare help.

Not only is Medicare not free, but your health care costs in retirement could be much higher than you think due to the number of services that Medicare does not cover. For example, Medicare does not cover dental exams, vision services, and hearing aids. But again, if there’s one major expense not covered by Medicare to watch out for, it’s none other than long-term care.

Conversely, Medicaid will cover the costs of nursing home care or skilled medical care provided at home. However, because Medicaid is a needs-based welfare program, the only way to qualify for benefits is to spend next to nothing (usually around $2,000 in most states).

In addition, the quality of care and the facilities where care is provided are determined by the state and depend on the availability of these resources. So even if you qualify for Medicaid, you may not be guaranteed admission to a nursing home until a bed becomes available. For these reasons, Medicaid should be a last resort when funding long-term care.

Many people mistakenly believe that “other health insurers” will pay for their long-term care. The surprising truth is that long-term care is NOT covered by any other type of insurance, including your HMO, health insurance, or long-term disability insurance. Only long-term care insurance, which you usually purchase yourself, covers day-to-day personal care when you can’t perform daily activities like bathing and dressing.

Make October the month you talk to a certified financial planner or elder law attorney about long-term care. Let them help you better understand how government policies and private programs can work together for better quality care when you or your loved ones are most vulnerable.

Thinking about long-term care may not be fun or exciting, but it can benefit you and your family. Knowing that you have a plan for where and how you want to live as you age can make you feel more secure and confident about your future. A plan will help family members prepare to help you with your care or find your preferred caregiver, and the financial logistics won’t surprise you. It’s your life… Plan it!

(Joel Mekler is a Certified Senior Counselor. Send your Medicare questions to him at [email protected])

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