Medicare: Know what it does not cover

Published 9:39 am Monday, June 8, 2020

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Ron Kauffman

Senior Lifestyles


In less than ten years from now, approximately 66 million Americans will have reached retirement, and many may have needs that vary from in-home care to assisted living and for some, long term or custodial care in a nursing home. Too many will be surprised to find out that what they expected Medicare to cover, is not covered. One major misunderstanding is that Medicare covers custodial care. That’s not true. It does not.

It’s important that you understand Medicare’s rules and know that not all Medicare plans are equal. Don’t assume that you know what is covered. For instance, most Medicare plans do cover a limited time spent as a rehabilitation patient in a skilled nursing facility. But Medicare covers only what a physician deems to be medically necessary while there.

Except for rehabilitation time spent in a skilled nursing facility, all costs for nursing home, assisted living facilities, and life care residence is to be borne by the resident. The only exceptions are if the patient has a long term care insurance policy that covers some or all of the expenses, or if the patient is a qualified recipient of Medicaid.

Most assisted living facilities provide meals, housekeeping, laundry, security services and social activities as well as the availability of staff members around the clock. Some facilities offer other services like prescription medicine management at additional cost. In North Carolina all facilities licensed by the State must have a medical director available as needed to provide basic medical services. Keep in mind that the primary purpose of an assisted living facility is to help people live independently with as little direct assistance as possible.

Misconceptions about Medicare tend to occur in situations where a patient may need post-incident (surgery, heart attack, broken hip etc.) rehabilitation and recovery versus custodial care. In situations requiring a short-term stay in a skilled nursing facility, Medicare typically pays for covered costs including semiprivate rooms, meals, skilled care, required medication, medical supplies and equipment, physical, occupational and speech therapy.

Rehabilitation, even in a skilled nursing facility is typically focused on providing 24/7 medical and nursing care, but only for a short stay which is frequently reevaluated to determine when the maximum recovery level has been achieved. The goal is to help a person become well enough to return home and live independently. When the patient is discharged from this type of facility, Medicare may continue to pay for some short term services provided to the patient at his or her home a few hours per week.

The requirements for nursing home and rehabilitation services for the receipt of benefits are that the patient must have Medicare Part A coverage, was admitted as an in-patient to a hospital for at least three days before entering the nursing facility. Once eligibility has been established, Medicare Part A pays for some costs for a limited period of time, not to exceed a maximum of 100 days. If that is exceeded, it is not covered by Medicare and will be charged directly to the patient.

Keep in mind that while Medicare does cover all costs for patients admitted under a medical doctor’s orders to Hospice, it does NOT pay for long-term custodial care in a nursing home, an Alzheimer’s or Dementia facility or for 24-hour care at home.

Understanding what Medicare covers and doing financial and “what if” planning for your future before it arrives, whether through long-term care insurance, family arrangements, or use of personal assets, doing so can prevent a great deal of emotional and financial turmoil for you, your spouse and family.

Ron Kauffman is a Consultant & Expert Speaker on Issues of Aging. Contact him at 828-696-9799 or by email at: