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Medicare and Long-Term Care: What to Expect

Medicare is the health care insurance program for Americans who are 65 and older. It’s not entirely free – most participants pay premiums and copays – but it covers hospitalization, doctor visits, medical equipment and supplies, prescription drugs and more.

However, many people assume Medicare will also cover long-term care, like an in-home aide or unskilled care in a nursing home.

It won’t.

Because of the complexity of the program, you may not know exactly what Medicare will or won’t cover.

We can help.

Our Medicare Medicaid Assistance Program (MMAP)  provides unbiased help with Medicare and Medicaid at no charge. Our team of counselors answers questions, troubleshoots problems and helps people understand their Medicare plan choices. Government funding allows us to offer this valuable, impartial assistance for free.

“Medicare can be very complicated. We encourage everyone who is about to go on Medicare to give us a call and have an unbiased counselor explain the program and the different options. This way, you can plan ahead and know what your monthly costs will be,” says Shari Smith, manager of AAA 1-B’s Medicare Medicaid Assistance Program (MMAP).

Following is a breakdown of the program– what it will and won’t provide in the short- and long-term:

Medicare covers health care for people 65 and older and people who have been on disability for at least 24 months.

Part A covers hospital, hospice care and some nursing home care. There is no monthly premium for people who’ve worked at least 10 years and paid Medicare taxes. You’re automatically enrolled in Part A when you turn 65.

Part B covers doctor visits, medical equipment, lab tests, ambulance services,mental health services, preventive care and more, and it comes with a small monthly premium (around $135). If you don’t have health coverage through an employer, you must enroll during the period that spans three months before and after your 65th birthday or pay a late enrollment penalty. If you meet financial eligibility requirements, you can get help paying your premium with the Medicare Savings Program.

Part D covers prescription drugs. It also requires that you pay a premium – which varies according to the plan you choose, unless you qualify for Extra Help. If you don’t sign up when you turn 65, you may pay a permanent late enrollment penalty.

You can also opt for a Part C (Medicare Advantage) Plan which combines Parts A and B coverage into a private insurance plan that is structured as an HMO or PPO. These plans, which vary in cost and scope, provide all hospital and outpatient care (Parts A and B). Some plans will include prescription drug coverage (Part D). Medicare Advantage plans may require you to get referrals before you see specialists or choose doctors from a specific network, but they often offer additional coverage like dental, vision and hearing, and most include prescription drug coverage. As of 2019, some Medicare Advantage plans began to cover the cost of home modifications to accommodate walkers and wheelchairs and home-delivered meals nutritionally tailored to customers with diabetes or chronic heart failure.

Medigap plans, which are sold by insurance companies and require a monthly premium, are designed to fill in Parts A and Part B coverage gaps, including hospital stays.

Medicare won’t cover:
■ Most dental care*
■ Eye exams related to prescribing glasses*
■ Dentures
■ Cosmetic surgery
■ Acupuncture
■ Hearing aids and exams for fitting them
■ Routine foot care
*Some Medicare Advantage plans may offer this coverage.

LONG-TERM CARE COVERAGE

Here’s what you can expect from Medicare when it comes to longterm care:

Medicare and Nursing Home Care

Medicare will NOT cover long-term nursing home care. Medicare will only cover a nursing home stay following a hospital admission when a doctor has ordered skilled nursing and therapy services. The needed care must be related to the condition for which you were treated in the hospital.

Medicare Parts A and B will cover the cost of a nursing home stay for up to 100 days following hospital admission of three or more days and with a doctor’s order. The following services will be covered:

■ Semi-private room (a room you share with other patients)
■ Meals
■ Skilled nursing care
■ Physical and occupational therapy (if they’re needed to meet your health goal)
■ Speech-language pathology services (if they’re needed to meet your health goal)
■ Medical social services
■ Medications
■ Medical supplies and equipment used in the facility
■ Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the skilled nursing facility
■ Dietary counseling
■ Swing bed services

After day 20 in a skilled nursing facility, you will have to pay $170.50 per day (2019 rate), unless you have a Medigap policy that provides coverage for the copay.

MEDICARE AND HOSPICE CARE

The goal of hospice care is to maintain or improve the quality of life for someone who is not expected to live beyond six months. Depending on the nature of the illness or disease, hospice care involves a team that may include a doctor, nurse, social worker, nutritionist, and various therapists to address end-of-life issues — physical, emotional and spiritual.

Medicare Part A will cover most of the costs of hospice care in the home or in a facility if the person’s hospice or regular doctor certifies that the person has a terminal illness with a life expectancy of six months or less. The person must sign a statement that he or she is choosing hospice over Medicare-covered treatments for the illness. In that case, Medicare won’t cover any treatment, including prescription drugs, intended to cure the illness or related conditions.

Medicare will cover:

■ Doctor, nurse and social work services set up by the hospice care team
■ Prescription drugs for symptom and pain control (there may be a $5 charge for medications)
■ Hospice aide and homemaker services
■ Medical supplies and equipment (bandages and catheters, wheelchairs and walkers, e.g.)
■ Physical, occupational and speech therapy
■ Dietary counseling
■ Grief and loss counseling
■ Short-term inpatient care for pain and symptom management
■ Short-term respite care in a Medicare-approved facility (nursing home, hospital)
■ Other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness and related conditions, as recommended by your hospice team
■ If the person lives beyond six months, Medicare will continue to cover hospice care, as long as the hospice medical director or hospice doctor recertifies (at a face-to-face meeting) that the person is terminally ill. The patient can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods.

A person has the right to change his/her hospice provider once during each benefit period. Contact your hospice team before you get any of these services or you might have to pay the entire hospice care cost.

AFFORDING MEDICARE

Extra Help

This is a Medicare program that helps people with limited financial resources pay Part D prescription drug premiums, co-insurance and deductibles. You automatically qualify for Extra Help if you:

■ Have full Medicaid coverage
■ Are enrolled in a Medicare Savings Program
■ Get Supplemental Security Income benefits

If you receive a purple notice, it means you automatically qualify for Extra Help. A yellow or green notice means you have automatically been enrolled in a specific prescription drug plan, which you can change during a Special Enrollment Period. You may qualify for Extra Help if you have a higher income or have dependents in the home.

Medicare Savings Programs

If you meet income and asset eligibility requirements, you can apply for help from the State of Michigan to help pay your Medicare premiums, deductibles, co-insurance and co-payments for Medicare Parts A and B. There are four Medicare Savings programs. If you qualify for the any of the first three listed, you automatically qualify for Extra Help. Keep in mind that you can be getting an income from work and still qualify:

■ Qualified Medicare Beneficiary (QMB): QMB helps offset premiums, deductibles, coinsurance and copayments for Parts A and B.
■ Specified Low-Income Medicare Beneficiary (SLMB) Program: SLMB helps cover Part B premiums.
■ Qualifying Individual (QI)Program: This is a program which requires you to apply every year, and is on a first, come-first served basis. QI helps cover Part B premiums. To qualify, you can’t be
eligible for Medicaid.
■ Qualified Disabled and Working Individuals (QDWI) Program: QDWI helps pay the Part A premium if you are a working, disabled person under age 65 and lost Social Security Disability benefits (which entitled you to premium-free Part A Medicare) when you returned to work.

OUR MEDICARE MEDICAID ASSISTANCE PROGRAM (MMAP) CAN HELP

The Area Agency on Aging 1-B’s Medicare Medicaid Assistance Program (MMAP) can help you understand your options and help you enroll in a plan that works for you, either over the phone or in-person – free of charge. Callus at 800-803-7174.