Medicare can be difficult to navigate and even harder to explain to those with no experience.
While administrators and directors of senior care facilities may understand the nuisances of Medicare coverage for their services, many seniors and their families do not. Here are 6 tips senior facility directors can use to help families and residents get to the core of Medicare long-term care coverage. These tips provide a clear path through the chaos so that you can answer your new resident’s questions easily and provide them with additional resources to help pay for their facility care.
Medicare is healthcare offered by the federal government to those who meet the requirements. It is often used by the elderly once they are no longer covered under an employer’s healthcare insurance. Medicare is the single biggest payer, and as of 2021, Medicare beneficiaries numbered 63,964,675. However, most people approaching enrollment age don’t know how much Medicare covers or how much long-term care can cost. Currently, the average daily cost for a nursing home is $260 for a semi-private room. That means a shared room is $94,900 a year.
These Medicare tips for seniors provide answers to the most common questions about Medicare’s coverage of assisted living costs.
Tip #1: Know Medicare Basics
Medicare help for seniors starts with understanding the basics of what the resident needs and what Medicare offers. Original Medicare has no monthly premium if you qualify, but you will need to pay deductibles, copays, and some out-of-pocket costs. Services covered are based on state and federal laws, and coverage rules are based on national Medicare and local company decisions. Benefits can also vary widely from case to case.
Medicare currently has 3 main components separated into parts: Original Medicare (parts A, B, and D), Medicare Advantage Plan (part C), and Medigap.
- Part A coverage is about where the patient will receive their care. It covers some facility costs like hospitalization, hospice, and inpatient care in skilled nursing facilities for short-term stays.
- Part B coverage is about medical services. It covers some medical costs like doctor visits, services, and supplies.
- Part D, also known as PDP or Prescription Drug Plans, covers some or all of the patient’s prescription drug costs.
- Part C, known as Medicare Advantage Plans. Also called MA Plans, these are separate plans available through private health insurance companies and paid for by both you and the federal government. You will not have Medicare Parts A or B if you select a Medicare Advantage Plan, as those services will be covered by the MA Plan. Medicare Advantage Plans will usually cover more services than the original Medicare.
- Medigap, known as Medicare Supplemental Insurance. These are separate, private health insurance plans sold to Medicare and may help defer costs like copays and deductibles. It is used to fill in the gaps between Medicare Part A and B.
Tip #2: Know What is Covered by Medicare and What Isn’t.
When navigating Medicare, you will notice that Medicare doesn’t cover any substantial long-term care (also known as custodial care.) Medicare Advantage Plans may pay for some related services, but coverage varies by individual plans and states. Here are some types of long-term care facilities and what Medicare parts A, B, D, and C will cover:
Independent Living
Medicare basic doesn’t cover independent living, and Medicare Advantage (Part C) may only pay for some services provided with independent living.
Assisted Living
Medicare Part A covers short-term care in assisted living facilities for acute injury rehabilitation after a related hospital stay, or if a doctor determines the patient needs end-of-life care. This care must be in a Medicare-approved facility. The care must be provided for less than seven days a week or less than eight hours a day over a 21-day period. There can be exceptions. Medicare does not cover long-term assisted living.
Memory Care
Medicare doesn’t cover room and board but may cover mobility assistance devices, GPS trackers (Part C), and a few prescription drugs (Part D) related to memory care.
Skilled Nursing Facilities (SNF)/Nursing Homes
Medicare does not cover long-term care in a skilled nursing facility or nursing home. It will cover some of the costs of palliative care and hospice care (6 months).
If you meet the criteria, Medicare will pay for 100 days in a skilled nursing facility after three nights in a hospital. The patient’s health must be improving and requires skilled care with the goal of returning home. Medicare allows twenty days free, then Medicare covers some cost of the next 21-100 days. Seniors pay co-insurance, around $170 daily, usually covered by Medicare supplement plans after the first 100 days. Examples of injuries or diseases covered are stroke, broken bones, and after-surgery care.
Home Care
Home care, also called aging-in-place, is becoming a popular option for senior care, but it will still carry additional costs. Medicare doesn’t cover long-term home care or in-home 24-hour care. Parts A and B will contribute to costs in which services rendered equal less than eight hours in a 21-day period. The services must be doctor prescribed and arranged by a Medicare-certified agency. Medicare Part B will cover some physical therapy, occupational therapy, and speech therapy. Medicare doesn’t pay for 24-hour supervision, meal prep or delivery, daily tasks like shopping or cleaning, or personal care services like bathing.
In summary, Medicare doesn’t pay for long-term care and doesn’t cover non-skilled assistance with life’s daily activities, which is the type of care given in assisted living facilities. No matter what senior care facility you live in, Medicare will cover some medical services and prescription drugs as if you were at home.
Of all the Medicare tips for seniors, advising your resident to look into Medicare Part C (Advantage Plans) and additional government programs is key. Additional health insurance plans are available in the thousands and may help defer some of the cost of long-term senior care.
Tip #3: Know Who Is Eligible for Medicare
To be eligible for Medicare original Parts A, B, D, Medicare Advantage Plans, and Medigap, you need to be an American citizen or permanent resident who:
- Is aged 65 years or older and has paid taxes for ten consecutive years.
- Has a disability qualified by the Social Security Administration.
- Has ALS (Lou Gehrig’s disease).
- Has end-stage renal failure.
- Has Railroad Retirement Board Benefits.
- Has a kidney transplant and kidney dialysis.
Tip #4: Know Enrollment Procedures and Deadlines
To help seniors with Medicare, we first need to get them enrolled during open enrollment or within seven months of the patient’s 65 birthday. People who have paid taxes for ten years and are aged 65 or older receiving Social Security Benefits automatically receive Part A. Parts B and D require paperwork and opting in.
Part C (Medicare Advantage Plans) requires picking a plan, paperwork, monthly costs, and forfeiture of Medicare original Parts A and B.
Failure to meet deadlines for Medicare enrollment can lead to fees, penalties, and a higher premium. Visit the Social Security Administration’s website to see the requirements and to start the application.
Tip #5: Know if Your Resident Needs Supplemental Insurance
A key piece of Medicare advice for seniors is knowing that they are likely to need supplemental insurance and additional funding for long-term care. Some sources include:
- Private or family funds
- Medicaid (a federal and state healthcare plan for people with minimal incomes)
- Private health insurance
- Life insurance options
- Annuities
Tip #6: Know Where to Get Additional Help
Future residents of long-term care facilities need to know that there are government assistance programs that can help them pay for care and navigate the maze of healthcare options. Some of these programs are:
PACE (Program of All-Inclusive Care for the Elderly)
- 1-877-267-2323
- Available in certain states, PACE is a Medicare program that covers medical, social services, and long-term care for people who still reside in the community.
SHIP (State Health Insurance Program)
- 1-877-839-2675
- SHIP is available in every state and provides assistance and counseling to help seniors navigate Original Medicare, Medicare Advantage Plans (part C), Medigap, and Medicaid.
The VA (Department of Veterans Affairs)
- 1-877-222-8387
- The VA may help veterans and their qualifying family members pay for long-term care in a facility or at home.
SSA (Social Security Administration)
- 1-800-772-1213
- There are two programs provided by the U.S. Social Security Administration that can help cover some costs of living for disabled Americans. SSDI (Social Security Disability Insurance) is financial assistance for disabled people under age 65, and SSI (Supplemental Security Income) is for disabled people 65 years or older. The SSA has very precise criteria to determine disability as well as income requirements.
NCOA (National Council on Aging)
- 1-571-527-3900
- The NCOA is not a government group but a private organization. BenefitsCheckUp® is their free service that helps connect seniors and people with disabilities to benefit programs in their area.
CME (Centers for Medicare & Medicaid Services)
- 1-800-Medicare (1-800-633-4227)
- If you need detailed information on public healthcare programs and long-term care, this government website is a great place to start.
Benefits.gov
- 1-800-FED-INFO (1-800-333-4636)
- Local, state, and federal benefit information on public benefits.
The ACL (Administration for Community Living, also known as LongTermCare.gov)
- Administration for Community Living: (202) 401-4634
- Eldercare Locator (to find local resources): (800) 677-1116
- This site provides detailed information about financing options and benefit coverages.
Senior care facility directors and administrators are often called upon to help others navigate the Medicare maze. The best Medicare advice for seniors begins by identifying the patient’s specific needs and their sources of external funding, and then you can help them find the programs that will benefit them the most. Your residents and their families are likely to have many questions about Medicare and how to pay for long-term care in facilities, so having the right information and an understanding of what is available will save you and your clients time, money, and frustration.
