Medicare: How do skilled nursing care, long-term care differ?

Dear Toni: Recently in your column, you discussed services that are not covered by original Medicare such as dental, vision, long-term care and other items.

I thought Medicare covered long-term care but was wrong, because my mother suffered a severe stroke and her rehab facility notified me that Medicare is not paying for her care. Beginning next week, for her to receive care from this facility, it will have to be private pay or she will have to go home.

I need help understanding this confusing Medicare system. What is the difference between rehab/skilled nursing care and long-term care? I thought they were both the same. — Sue, Little Rock, Arkansas

Dear Sue: Trying to understand the rules of Medicare when a loved one has a severe illness and requires medical and custodial care is very frustrating. People are living longer today and want to control their quality of care, especially when they need assistance as their health begins to change.

I will try to explain what long-term care is in simple terms.

The 2024 “Medicare &You” handbook, under “Paying for long-term care,” discusses how important it is to plan now to maintain your independence and receive the proper care in the setting you desire. Medicare pays only for medically necessary skilled nursing facility care or for home health care if you meet certain conditions.

Skilled nursing has 100 days of benefits with a $0 copay per day for days 1-20 and a specified copay per day for days 21-100. If you cannot qualify or do not meet Medicare’s qualification for skilled nursing, you will pay 100 percent of the cost out of pocket.

This is when having purchased a long-term care policy becomes essential.

Long-term care includes medical and nonmedical care for those who have a chronic illness or disability. At least 70 percent of people over 65 will need long-term care services at some point. Long-term care can be provided at home, in an assisted living facility, personal care home or nursing home.

This care can be very expensive, with an average cost ranging from $54,000 a year for a one-bedroom assisted living facility to $94,900 for a nursing home. Original Medicare does not pay for these services.

Below are some options to pay for long-term care:

1. Purchase a long-term care insurance policy. The younger you are when you purchase a long-term care policy, the lower the premiums will be. Many wait too long and qualifying is not easy because of health issues. Begin searching for a plan while you are younger and in good health.

2. Purchase a life insurance policy with a long-term care provision. Many life policies have such a provision so that you can receive a certain amount of your life policy’s face amount.

3. Qualify for Medicaid. Research what the qualifications are for your specific state’s Medicaid. Verify what must be “spent down” to qualify.

4. Utilize veterans benefits. Aid and attendance benefits with the VA can help veterans and spouses with long-term care issues.

5. Dedicate personal resources such as savings, IRA or 401(k) to help pay for long-term care.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.