When Medicare Won’t Pay For Nursing Home Care
Shereen Lehman, MS, is a healthcare journalist and fact checker. She has co-authored two books for the popular Dummies Series .
Medicare is not a one-stop-shop. While it covers a wide breadth of services, it may leave you to fend for yourself when it comes to certain healthcare essentials as you grow older. For example, it doesn’t cover corrective lenses , dentures, hearing aids, or white canes for the blind. Certain medications are off the table, too, even if you have a Part D prescription drug plan.
This is because Medicare does not consider these things to be medically necessary. Unfortunately, what they also do not see as medically necessary are custodial care and long-term nursing home placement.
Medicare Coverage By Part
- any age and have a disability
- any age and have end stage renal disease
However, there are also some specific Medicare plans that people with dementia may be eligible for. In these cases, a diagnosis of dementia may be required:
- Special needs plans :SNPs are a special group of Advantage plans that specifically address the needs of people with specific health conditions, including dementia. Coordination of care is also often included.
- Chronic care management services : If you have dementia and at least one more chronic condition, you may be eligible for CCMR. CCMR includes development of a care plan, coordination of care and medications, and 24/7 access to a qualified healthcare professional for health needs.
Dementia happens when you lose cognitive abilities like memory, thinking, and decision-making. This can significantly impact social function and activities of daily living. For example, a person with dementia may have difficulty:
- recalling people, old memories, or directions
- carrying out daily tasks independently
- communicating or finding the right words
- solving problems
- paying attention
- controlling their emotions
There isnt just one type of dementia. There are actually several types, each with different characteristics. They include:
Does Medicaid Pay For Memory Care
Though not all communities accept Medicaid, the program does pay for 24-hour dementia care in many memory care facilities as well as memory-related care in skilled nursing communities. This usually includes all costs associated with room and board. Under Medicaid policies, seniors must forfeit most of their available income including Social Security checks toward their care and can retain only a small monthly personal allowance. Allowance amounts differ by state but typically are less than $75.
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Medicaid Benefits And Early Stages Of Dementia
Patients who are only beginning to show symptoms of dementia may benefit from home-care services. These services often appeal to the individual and their loved ones because they provide the support they need at more reasonable costs than full-time nursing facility care. The costs can still be significant, however. Medicaid, thankfully, can help with these types of costs.
Medicaid will only pay for your loved ones in-home care if they would otherwise need to relocate to a nursing home.
In other words, a medical professional must deem that without in-home care, the individual with dementia or Alzheimers cannot live safely outside of a full-time care facility. Without this documentation in place, Medicaid will not pay for such services.
Similarly, Medicaid pays for adult day care programs when a hybrid solution is necessary and deemed safe for the individual. The day care facility in these situations provide the necessary supervision and/or nursing assistance during the day while caregivers are at work. Then in the evenings, the caregiver lives with and cares for the individual with dementia during non-working hours and days. This keeps costs down for everyone compared to a full-time facility and gives the person suffering with dementia the comforts of a familiar place and people every day.
Does Medicare Cover Alzheimers Disease
Original Medicare does not address Alzheimers disease or other dementias as a single diagnosis with universal coverage, but it does cover in-patient hospital care and some related expenses.2 Thats why after an Alzheimers diagnosis, theres not always a direct path to ensure that Medicare will cover allor mostof the treatment costs.
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Does Medicare Advantage Cover In
Switching to a Medicare Advantage plan means you may be able to get coverage for some in-home services and possibly lower your out-of-pocket costs.
The additional coverage options, restrictions and out-of-pocket costs may vary from plan to plan, and not every plan covers in-home support services. Some plans require you to get prior authorization from your doctor for in-home services while others may require that your care come from an agency that contracts with your specific plan.
These supplemental benefits that are offered only through Medicare Advantage focus on your physical and emotional well-being, safety and your quality of life.6
Home Safety Improvements
Medicare Advantage plans now have the option of covering certain improvements to make your home safer and easier to navigate. These improvements include installation of shower grips and toilet rails, wheelchair ramps and wider door openings.
You may also qualify for additional home services, such as carpet cleaning and the installation of air purifiers to prevent allergy and asthma attacks.
Personal Care Services
More and more healthcare professionals recognize that quality of life is an important factor in your physical, mental and emotional well-being. Medicare Advantage plans now have the option of offering a host of personal care services to improve your quality of life. These services can include assistance with bathing, dressing and oral hygiene.
Payment Options / Financial Assistance For Alzheimers Care
For most families, the expenses of caring for a loved one with Alzheimers or dementia are covered not by a single source, but instead by contributions from a variety of sources. Some of these resources are specifically designed for Alzheimers patients and others are of a more general nature.
Dementia Care Central is a free website that offers tips, suggestions, and videos on how to provide hands on care and gain the cooperation of persons with Alzheimers. Visit their site.
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When You Need Part
Updated By Bethany K. Laurence, Attorney
Progressive health care professionals often encourage people to get out of hospitals and nursing facilities and into their own or family members homes while recovering from injury or illness. With less honorable motives, insurance companies also pressure hospitals to release patients earlier so that if they continue to receive care, it will be a less costly variety at home.
In response to both these movements, many new home health care agencies have sprung up. Youre increasingly likely to find such an agency in your local area. Most are able to provide care for patients who no longer need high-level care in a hospital but who still require part-time nursing or rehabilitative therapy.
Medicare Advantage Plans May Offer More Benefits For Dementia Care
As part of the Chronic Care Act of 2018, Medicare Advantage plan providers are able to provide expanded benefits to their beneficiaries, called supplemental benefits, starting in 2019 and 2020.
Some of these additional benefits may include:
- Home modifications, such as bathroom grab bars
- Non-medical home care, such as custodial care
- Adult day care
Because Medicare Advantage plans are sold by private insurance companies, plan availability and the benefits they offer may vary from one location to another.
To learn more about Medicare Advantage plans in your area, your eligibility to enroll, and the benefits that they offer, call to speak with a licensed insurance agent today.
Compare Medicare Advantage plans in your area
Or call 1-800-557-6059TTY Users: 711 24/7 to speak with a licensed insurance agent.
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When Should A Dementia Patient Go To A Nursing Home
Even though you prefer the quality of life for your family members to be at home, if you feel that you are unable to provide them with adequate care, it could be time to consider a nursing home. During resident care, nursing homes offer a customized treatment program, diet guidelines that are healthy, and 24 hour emotional and behavioral support.
Prescription Drug Coverage: Medicare Part D And Part C
Although it doesnt directly relate to home health care, its important to keep Part D plans in mind. If youre seeking comprehensive Medicare coverage, a Part D plan will be required if you want coverage for prescription drugs.
These plans are private and can vary with respect to which drugs they cover. Make sure to look at the details of each plan individually.
The other way to get prescription drug coverage is through a Part C plan. Not all Part C plans offer prescription drug coverage, but some do. If your plan offers drug coverage, you wont be able to purchase a Part D plan in addition to your Part C plan.
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How To Get Medicaid To Cover Dementia Care Costs
One of the biggest difficulties with dementia is that people with it typically dont have enough clear judgment to appraise a situation, thus family members must make all of the decisions.
This is why, as soon as you receive a diagnosis, you should establish a power of attorney or seek court permission.
This will help with all of the documentation that will be required in the future for appropriate treatment and convergence by Medicaid.
Do Advantage Plans Cover Any Part Of It
Medicare Advantage plans dont usually cover nursing home care thats considered custodial care. A few exceptions exist, including if a persons plan has a contract with a specific nursing home or organization that operates nursing homes.
Always contact your plan provider before going to a particular nursing home so you understand what services are and arent covered under your Medicare Advantage plan.
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Does Medicare Cover Alzheimer’s Care: What You Should Know
Learn about what Medicare does and does not cover for Alzheimers care. Seniorly can put the pieces together for you and your loved ones to make the best possible decisions about Alzheimers care.
The Alzheimer’s Association estimates that more than 5 million people in the United States are living with Alzheimer’s Disease. That number is projected to reach 14 million by 2050, so it’s important for families and caregivers to understand what options they have when it comes to care. We’ll walk you through how Medicare works for those who suffer from this disease, as well as some other considerations that may affect your decision of where to live and type of care if you or a loved one are diagnosed with different forms of dementia or Alzheimer’s.
Find Dementia Care Through Medicare Advantage Plans
Dealing with dementia is stressful enough. You shouldnt have to worry about paying for your loved ones dementia care. While original Medicare cant help out very much, a Medicare Advantage plan might be able to cover some of your loved ones needs when it comes to individuals with dementia.
If youre ready to learn more about how Medicare Advantage can help with assisted living for dementia, you should shop around for quotes. If youre ready to see what quotes might look like for you, enter your ZIP code into our free tool.
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If Custodial Care Is All You Need Medicare May Not Cover It
Medicare offers pretty limited coverage for nursing home care, but it can help offset the costs of a short-term stay or related medical services. If what Medicare offers isnt enough, you have other options, though. Read on to see what Medicare can do for you and what your alternatives are if you need more help.
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Does Medicare Advantage Cover Long
Medicare does not cover the cost for long-term assisted living facilities. But some Medicare Advantage plans, also known as Medicare Part C, pay for several related services.
More than 22 million Americans are already enrolled in Medicare Advantage and there are now more than 3,100 plans available nationwide.1
Families, social workers, doctors, and other healthcare workers can help figure out the best care arrangement for you or your loved ones. We can help you understand your options and get you started on the path to enrolling in a Medicare Advantage plan.2
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Does Medicare Cover Alzheimers Screenings
The Medicare Annual Wellness Visit includes screening for cognitive impairment to identify if you have any memory illnesses. During the screening, your doctor may talk to you about your life and any possible concerns.
Your doctor can discuss screening results, prescribe medications, recommend resources to help you plan for the future, and refer you to a specialist. Medicare pays the full cost of Alzheimers screening as a preventive service.
Does Medicare Pay For Home Health Care
There is an important distinction between medically necessary home health care and personal care services provided by an unskilled caregiver. Understanding the difference between these two levels of care is key to determining who is eligible for Medicare-covered in-home services. For more information on this topic, read The Difference Between Home Health Care and Non-Medical Home Care Services.
Only home health care services prescribed by a doctor and provided by skilled caregivers are covered by Medicare, but patients must meet specific eligibility requirements.
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Respite Care For Alzheimers Caregivers
Respite care is temporary assistance provided to the primary caregiver to allow them a break from caring for an individual with Alzheimers or dementia. It can be provided in the home, in an adult day care center, or sometimes in an assisted living residence or other residential setting. Respite care is sometimes provided free of charge or other times at a greatly reduced hourly rate. There are many different organizations and programs offering respite care services. It is worth noting that often times these are home care companies selling home care and marketing it as respite care even though they are charging the full hourly rate.
There are also federally funded programs that provide reduced rate or free respite care, such as the Lifespan Respite Care, the National Family Caregiver Support Program, as well as programs specific to individual states including Floridas Project R.E.L.I.E.F., New Jerseys Statewide Respite Care, and Connecticut Statewide Respite Care Program.
Does Medicare Cover Assisted Living For Dementia
When dementia interferes with the daily life of a loved one, many families and caregivers consider an assisted living facility. Assisted living is a type of long-term care of services and supports for personal care needs, which include activities of daily living like housekeeping, dressing, bathing, meal preparation, eating, medication management, and mobility. If youre considering moving someone you care about into an assisted living facility, understand that Medicare will not pay for these types of personal care costs, nor will it cover room and board. However, these may be some other options to help cover the costs of dementia-related items and services.
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Medicare Coverage: What Is A Medicare Special Needs Plan
A Special Needs Plan is Medicare coverage available through a type of Medicare Advantage plan.
A Chronic Condition SNP covers people who qualify by having a certain health condition. Your mom must have that condition to be able to enroll in one of these plans. There are SNPs for people with dementia. You can search Medicare Advantage plans in your momâs area by entering his zip code in the box on this page.
Private insurance companies approved by Medicare can offer these plans. SNPs can charge a monthly premium. Your parent will also continue paying a Part B monthly premium. Some SNPs might pay a part of the Part B premium, if your parent qualifies.
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Skilled Nursing Facilities Care
Skilled nursing facility care is nursing or therapy that requires supervision or performed by technical personnel. Medicare Part A will cover SNF care for a limited time if:
- There are days left to use in your benefit period
- You qualify for a hospital stay
- The SNF is Medicare certified
- Your doctor recommends daily skilled nursing care or therapy
- You need services for a hospital-related medical condition or a condition that started while in the SNF, like an infection
Youâll want to learn more about SNF Medicare coverage before deciding if this is the long-term care you want for your elderly parents.
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Medicare Advantage: More Care Options
Medicare Advantage, also known as Medicare Part C, allows you to purchase a health insurance policy offered by a private insurance company, rather than the government. While Part C has some downsides, like provider networks, the main benefit that it offers is additional coverage.
While Medicare Advantage plans are regulated so that they must cover at least what Original Medicare covers, they are also free to cover more. This means that to stay competitive, many Medicare Advantage plans offer coverage that Original Medicare does not.
In most situations, this will be things like dental and vision plans. However, its also possible to find plans that offer coverage that may be useful for those who are dealing with dementia. This can include some coverage for custodial care as well as treatment options that arent classified as medically necessary. Coverage for nursing home care, memory care, and other assisted living facilities may be available as well.
Its important to note that these options will vary quite a lot between plans. They may also not be worth it financially: it could be that a plan is so expensive that its easier to pay the cost out-of-pocket. If youre looking at a Medicare Advantage plan, make sure you understand all of the details so you know if its a good fit for you. Still, this is an option that people who are looking for additional benefits should not ignore.