Medicare Long Term Care Facilities

Medicare Long Term Care Facilities – Source: Kaiser Family Foundation estimates based on the Census Bureau’s March 2016 Current Population Survey (CPS: Annual Social and Economic Supplement). Estimates based on analysis of data from the 2014 Medicaid Statistical Information System (MSIS). For less than a quarter of states with MSIS data, we also adjusted enrollment by using secondary data (specifically, the Medicaid Budget and Expenditure System) to represent the full fiscal year of enrollment. We accounted for state expansion status, the number of quarters of missing data, and historical patterns of state enrollment in making state-by-state adjustments. Because of these adjustments, enrollment estimates here are inconsistent with MSIS data or other analyzes based on states’ own reporting systems. Harrington, Carrillo and Garfield, based on OSCAR/CASPER data. Truven, Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2015, April 14, 2017. KCMU Medicaid Financial Eligibility Survey for Seniors and Individuals with Disabilities (2015).

Analysis of University of California, San Francisco and Kaiser Family Foundation On-Line Survey, Validation, and Reporting System (OSCAR) and Validation and Survey Provider Enhanced Reports (CASPER) data.

Medicare Long Term Care Facilities

Charlene Harrington, James H Swan, and Helen Carrillo, “Nursing Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities,”

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Kaiser Family Foundation estimates based on the Census Bureau’s March 2016 Current Population Survey (CPS: Annual Social and Economic Supplement).

Kaiser Family Foundation estimates based on analysis of data from 2015 National Health Expenditure Accounts data from CMS, Office of the Actuary and Urban Institute estimates from Kaiser Family Foundation estimates FY 2013 MSIS and CMS-64 reports. Because CO and RI data were unavailable in 2013, data from earlier years were used to align the 2013 CMS-64. Individuals who used both institutional and community services in the same year were classified as using institutional services.

Long-Term Care Providers and Service Users in the United States – State Estimates Supplement: National Study of Long-Term Care Providers, 2013-2014

Peter Kemper, Harriet L. Komisar, and Lisa Alexieh, “Long-Term Care in an Uncertain Future: What Can Current Retirees Expect?”,

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US Census Bureau, Population Division, Table 3: Population Estimates by Sex and Selected Age Groups for the United States: 2015 to 2060 (NP2014-T3), December 2014. About 63% of people age 65 and older will need additional care. At some point in their lifetime, and as life expectancy increases and the population of people aged 65 and over grows rapidly, that need is expected to increase as well.

Long-term care is not a specific service covered by your health insurance. Long-term care services are those that support health, finances, living arrangements, and help you navigate the legal, family, and other dynamics that come with it. The specific long-term care services someone needs will be unique to that person’s health, lifestyle, and financial situation.

Therefore, it’s important to plan ahead and learn what long-term care options Medicare may or may not cover, as well as what other resources are available to help you get the comprehensive long-term care you need.

In general, Original Medicare (Parts A & B) does not pay for most long-term care services or personal care services such as custodial care. There are some specific situations when Medicare will cover certain long-term care services.

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For all of the situations below, if you have a Medicare Advantage plan, your cost-sharing rules may be different. You need to understand with the plan provider how long-term care services may be covered and how your costs may vary.

Medicare may cover a skilled nursing facility stay if you need long-term care after a hospital stay

Medicare Part A will help pay part of the cost of a short stay (up to 100 days per benefit period) in a skilled nursing facility if you meet the following conditions:

The amount Medicare pays is based on the number of days you are in the facility. During each benefit period, the following coverage rules for Part A apply.

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Medicare Part A or Part B can cover various long-term care services and items as long as they are deemed medically necessary to treat an illness or injury. The following may be covered on an ongoing basis if (1) they remain a medical necessity and (2) your doctor reschedules them for you every 60 days.

Certain medical conditions may warrant additional coverage from Medicare. Medicare may cover long-term services to help prevent further decline due to medical conditions that do not improve over time, such as stroke or Alzheimer’s disease. You may want to check with Medicare or your Medicare plan provider about what services may be offered and how cost sharing works.

A special long-term care service, hospice care is unique in that Medicare Part A covers 100 percent of your hospice care costs. Generally, you will only be responsible for a $5 copay per prescription for any outpatient medications for pain and symptom management. (In some cases, although this is rare, your hospice benefits may not cover a certain drug, and you may need to see if your Part D coverage does). Some people may also pay up to 5 percent of the Medicare-approved amount for inpatient respite care.

Click here to learn more about hospice care with Medicare, how to qualify for Medicare-covered hospice, what hospice benefits Medicare will cover, and what Medicare won’t cover after you receive hospice benefits.

Medicaid Vs. Long Term Care Insurance: Comparing The Differences

Medicare may not be your only option for long-term care services. Medicaid also covers long-term care services provided in a nursing home or at home.

Medicaid may also cover some long-term care services that Medicare does not, such as custodial care. But, since Medicaid programs are state-specific, you need to check with your state’s Medicaid office to see if you qualify, and if you do, how your state’s Medicaid program coverage works. Some states offer additional benefits beyond those required federally. Here’s a helpful link from the Administration for Community Living on Medicaid and Long-Term Care.

Veterans with service-connected disabilities and other qualifying qualifications may be able to receive long-term care services paid for by the Department of Veterans Affairs. The VA can provide nursing home care, in-home care for older veterans with long-term care needs, and more. Veterans who do not have a service-connected disability but are unable to pay the cost of necessary care can also get the VA to pay for long-term care services. In addition, veterans may be able to benefit from two other care programs: the Housebound Aid and Attendance Allowance Program, and the Veteran Directed Home and Community-Based Services Program (VD-HCBS). Find out more about long-term care as a veteran here.

Many states have special programs designed to help older adults stay in their communities and be as independent as possible. Programs vary by state, but are generally administered through county, state, and federal resources (such as the Older Americans Act) and through state and local agency networks (the Aging Network). Services provided may vary but often include nutrition programs, transportation services, personal care assistance, and family caregiver services and supports.

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These programs typically have financial eligibility criteria — and are typically designed to target low-income, frail seniors over age 60, minority seniors, and seniors living in rural areas.

To find programs in your state and connect with your local Area Agency on Aging, click here.

Medicare Med Clear UnitedHealthcare offers Medicare education brought to you so you can make informed decisions about your health and Medicare coverage. Nursing home quality is a serious issue, especially in light of the risks to the people who live in them. Nursing home residents have significant limitations, including functional and/or cognitive limitations and multiple chronic conditions. While Medicaid is the primary payer for more than 60 percent of nursing facility residents, most people living in nursing homes are Medicare beneficiaries. 1 Some are short-term residents and enroll for Medicare-covered skilled nursing care after being hospitalized before returning. Continuing to stay for non-Medicare covered services at home or in the same or different facility. 2 Others are long-term residents, often with dementia, who live in nursing homes because they or their families are unable to care for them in their own homes. . Together, Medicare and Medicaid payments account for more than half (52 percent) of all expenditures on nursing home care, including care in skilled nursing facilities, nursing homes, and continuing care retirement communities.

Among Medicare beneficiaries who spend time in a long-term care facility or skilled nursing facility, 81 percent are limited in their ability to perform activities of daily living such as eating and bathing, 76 percent have cognitive or mental impairments, and 55 percent. According to an analysis of the 2010 Medicare Current Beneficiary Survey (Figure 1), 32 percent were in fair/poor health and had five or more chronic conditions. About two-thirds have incomes below $20,000. Women and people 85 and older account for a disproportionate share of nursing home residents.

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Figure 1: Medicare beneficiaries living in nursing facilities have significant functional and/or cognitive limitations and health problems

Nationwide, just over 15,500 nursing homes are certified to provide care to Medicare or Medicaid beneficiaries.

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