WHAT DOES MEDICARE PAY FOR SUMMARY FROM AN ELDER LAWYER

Many people living in Fairfield County CT or Westchester County NY assume that if they go into an assisted living facility or nursing home, Medicare will pay for it.

First, Medicare or Medicaid will not pay for assisted living.

Even in a nursing home, Medicare will only pay for a very limited amount.

Only Medicaid will pay for skilled nursing care and then only after you have essentially impoverished yourself.

Medicaid in CT and NY

So What does Medicare Pay For?

Hospital Costs

Medicare does not cover hospital costs beyond 150 days.

Long Term Care

Medicare does not cover skilled nursing home costs beyond 100 days.

Custodial Care

Medicare does not cover any custodial care, wherever given.

Home Care

Medicare does not cover any non- skilled home health care and may cover “skilled care”.  However, it is tough to qualify for the limited “skilled care” benefits, and all others are considered “custodial” patients.

Long Term Care Coverage in Detail

So, for long term care, the general rule is that Medicare doesn’t pay for long-term care.  In limited cases, it will pay for the first 100 days for skilled nursing and then you are on your own.

Skilled care is provided under the supervision of a doctor, requiring skilled professionals such as physical therapists or registered nurses, as opposed to “custodial care”, which provides basic personal care and other maintenance level services.

To qualify for the 100 days of coverage, you have to be in the hospital for 3 consecutive days or more. Time you are being observed in a hospital before you are admitted doesn’t count toward the 3-day qualifying inpatient hospital stay.

If you meet all of Medicare’s requirements, they will pay 100% of your first 20 days of care. Starting on day 21, you will pay $152 per day (increased each year based on inflation) through day 100. Medicare will not pay for your care after day 100.

Home health care may be available in limited amounts, but only if “medically necessary skilled care”, which is a very rigorous standard.

There are excellent insurance policies available to fill these “gaps” in Medicare coverage, appropriately called “Medigap” insurance, which must be purchased privately.

Fairfield County Connecticut and Westchester County New York have unique laws which require special planning.  So if you live in Wilton CT your results can vary from those of Bedford NY.