No one relishes the idea of being dependent on someone to help with routine tasks like getting dressed or bathing, but 60% of us will need these services during our lifetime. Because Medicare typically doesn’t cover the cost of this type of care on a long-term basis, planning is essential.
Regardless of whether you reside in a nursing home, assisted living facility, or you’re aging in place, neither Medicare nor Medigap provides insurance coverage for long-term custodial care. Some services, however, are covered on a temporary basis. This article sheds some light on the often confusing landscape of Medigap and long-term care.
About Medigap Plan Coverage
Medigap plans, also referred to as Medicare Supplement plans, are meant to fill in any so-called “gaps” in Original Medicare. As a reminder, Original Medicare consists of Medicare Part A and B.
Sometimes there is confusion about whether you can have both Medicare Advantage (referred to as Medicare Part C) and Medigap. You can have either a Medicare Advantage plan or a Medigap plan; you cannot have both. Further, Medigap policies purchased after 2005 don’t provide prescription drug coverage, so you’ll have to purchase Medicare Part D separately for prescription drugs.
Federal law provides that Medigap policies are purchased through private insurance companies, and there are ten different plans in all. Medigap plans are denoted by letters in the alphabet, starting with A and going through N.
However, Medigap plan availability varies by state, and some plans are not available to new Medicare beneficiaries. It’s important to note that you cannot be denied Medigap if you have pre-existing conditions as long as you purchase your policy within six months of enrolling in Medicare.
Regardless of the plan you choose, Medigap does not cover long-term care at assisted living facilities or for in-home care. The reason is that Medigap, by definition, fills the “gap” in existing Medicare coverage. Since Medicare doesn’t cover long-term care, neither does Medigap.
What is Long-Term Custodial Care?
There’s a difference between long-term care and long-term custodial care (sometimes referred to as personal care). While long-term care is associated with skilled medical services, custodial or personal care consists of non-skilled services. This care includes help with tasks associated with daily living, including:
- Getting dressed
- Using the toilet
- Meal prep
- Moving around the house
- Medication management
- Driving to appointments
These services are often required when you have a disability or chronic illness that makes completing these tasks independently difficult or impossible.
Is Long-Term Custodial Care Covered by Medigap?
Even though a Medigap policy can provide coverage for medical care beyond Original Medicare, it, unfortunately, doesn’t cover long-term care. While different insurance companies offering Medigap may vary their list of covered services, the lack of long-term care coverage under Medigap is universal.
There is limited coverage available for short-term care at a skilled nursing facility, but this Medicare coverage is typically limited to 100 days. There may be out-of-pocket costs, with Medigap policies covering anywhere from 50% to 100% of the cost of skilled nursing facility care.
Original Medicare also covers short-term skilled nursing care. Part A, which is hospital insurance, pays 100% of the cost of the facility for the first 20 days. After this initial period, Original Medicare pays 80%, and Medicare Supplemental insurance provides additional coverage up to the 100-day period.
To sum up, Medigap coverage can provide care temporarily for up to 100 days, but long-term care services are not paid for.
What Types of Care are Covered by Medicare?
Medicare covers custodial care and medical services on a temporary basis. Below is an outline of the coverage provided.
- Skilled nursing facilities: Medicare covers services received at a skilled nursing facility for 20 days, provided that the patient is admitted after an injury or having a heart attack or stroke. Further, the patient must have been hospitalized for at least three days and receive a doctor’s certification that skilled nursing care is required.
Medigap coverage can be applied to pay for coinsurance and copayments. Further, Medigap can also pay for stays in nursing homes that extend between 21 and 100 days.
- Home health care: After receiving nursing home care, a patient may be released but still need care in the patient’s home. While there is no specific time limit for receiving in-home care, home health services are meant to be temporary only. Further, they must be deemed medically necessary, and the patient must be home-bound.
An additional requirement is that the services are provided by a home health agency, and the scope of services, which includes medical social services, cannot exceed 8 hours per day and cannot be provided seven days per week.
- Outpatient rehabilitation services: Medicare pays for outpatient services such as physical therapy, speech-language pathology services, and occupational therapy.
To be eligible for coverage, physical therapy and other services must be medically necessary and be provided through a Medicare-approved provider (not family members, for example). Medigap can help cover the cost of copayments and coinsurance.
- Palliative care: Palliative care refers to when a patient has a severe illness that requires symptom management.
- Hospice care: Covered by Medicare part A, hospice care is for terminal illness, where the patient has a life expectancy of less than 6 months.
How to Pay for Long-Term Care
There are several options to pay for care, including the following:
- Long-term care annuity: Here, you pay monthly premiums to an insurance company, and you receive payments back when you need assistance paying for care.
- Long-term care insurance policy: You can buy a health insurance policy specifically for long-term care.
- Veterans Affairs benefits: The VA may cover a portion of the costs of long-term care for qualifying patients.
- Medicare Advantage Plans: These plans help cover costs up to 100 days.
- Medigap: Like Medicare Advantage plans, Medigap offers coverage for a longer period.
- Medicaid: Medicaid coverage allows you to receive long-term care at no cost.
- Personal funds: You can also use personal savings, a reverse mortgage, trust, or other investment funds.
If you need further assistance planning for long-term care, or you’re interested in switching from Medicare Advantage to Medigap, contact a Medicare Advantage specialist today.