[Last updated October 2, 2024]
As people age, they may need to pay for senior care services and wonder if Medicare covers long-term care costs. The short answer is that Medicare does not pay for much senior care or long-term care, although certain care-related services for seniors are covered on a short-term basis. The information below will help you understand and get the most out of your benefits.
What is Medicare, and who is eligible?
Medicare is a federal health insurance program for individuals who are 65 and older. Certain younger people living with disabilities may also qualify for Medicare. Note that though many people confuse the two, Medicare and Medicaid are different programs. Learn more about Medicare vs. Medicaid here.
When can I enroll?
When you turn 65, you enter an initial enrollment period — or IEP — that lasts for seven months. The IEP starts three months before your birth month and ends three months after your birth month. There is also a general enrollment period from January 1 through March 31, during which you can enroll in Medicare if you missed your original IEP.
Outside of this time, there is an open enrollment period each year from October 15 through December 7 during which you can add, drop, or change your coverage.
What long-term care does Medicare cover?
When you think of long-term care, you might think of assisted living facilities or nursing homes. More often than not, Medicare doesn’t cover this type of care. If the care you need is only custodial in nature, such as personal care tasks like using the bathroom, moving around, or getting dressed, Medicare will likely not cover the cost of that care because it is not considered medical. For example, Medicare will not cover a nursing home stay if you need only custodial care.
According to John Gorman, former assistant director of the U.S. Health Care Financing Administration, which is now the Centers for Medicare and Medicaid Services (CMS), under “traditional Medicare, long-term care is not really covered. Certain rehabilitation services are covered, but anything resembling custodial or personal care is not. Having a home health aide coming in is not covered; that would be Medicaid or private LTCi [long-term care insurance].”
Medicare does offer coverage for short-term stays in skilled nursing facilities if certain requirements are met.
Certain Medicare Advantage (Medicare Part C) plans may cover some long-term care costs. Note that Medicare and Medicare Advantage (MA) are two different types of health insurance coverage. Medicare Advantage is an alternative to original Medicare sold by private insurance companies. These policies often offer coverage for services original Medicare does not cover, such as vision and dental care. MA policies differ in what they cover, so people with MA should check their policy for details on whether it covers any senior care costs.
Custodial care vs. medically necessary care
To better understand whether Medicare covers the care you need, it’s helpful to know the differences between the terms “custodial care” and “medically necessary care.”
What does “custodial care” mean?
If a service is considered custodial in nature, Medicare typically does not cover it unless it’s deemed medically necessary. The Centers for Medicare and Medicaid Services defines custodial care as “nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops.” This is the type of care non-licensed caregivers can safely provide in a home or community setting and is generally not covered by Medicare.
What does “medically necessary care” mean?
On the other hand, medically necessary services are services “needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” These skilled services are medical in nature as opposed to custodial and require advanced medical licensure or certifications. This type of care is generally rendered under a doctor’s order. Examples include wound dressing, injections, and physical therapy.
Certain exceptions can be made in Medicare for services that aren’t covered if they’re deemed “medically necessary.” Under certain circumstances, Medicare may cover some medically necessary custodial care costs for a short time if the individual is also in need of medical care and the custodial care need is connected to the medical need.
How do you determine medical necessity?
Lindsay Malzone, the Medicare expert for Medigap.com, shares how you can assess if a treatment, item, or service is medically necessary:
1. Does your doctor use these items to diagnose a medical condition?
2. Does your doctor or medical facility provide these services or items for the direct care, diagnosis, or treatment of your illness or medical condition?
3. Do they meet the good medical practice standards for your area?
4. Are these services not primarily for your or your doctor’s convenience?
Verifying that the care you get is medically necessary can ensure timely approvals and coverage from Medicare.
Medicare covers health care, not long-term personal care
Medicare is health insurance that helps cover the cost of medical health care needs. If the care you need is determined to be medically necessary, that care may be covered. Otherwise, original Medicare typically will not pay for it, which is true for most long-term care services for seniors. When evaluating care, though, make sure that you check with local and state laws, as specific coverages and decisions may be different and based on different factors like medical necessity. You should also check your Medicare plan to learn the details of your coverage. Talk with your health care professional to learn more about your specific circumstances.
