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Financial Implications of Long-term Care: Medicare Coverage

US News reports that as of the last census in 2010, there were 40.3 million people ages 65 and over. That number jumped 5.3 percent from the prior census in 2000. As the Baby Boomers come of age, an ever-growing percentage of the population is living longer and healthier lives. That’s a good thing, but it also poses challenges — especially financially — when the time comes to think about long-term care at a facility like Princeton Health Care Center. Can Medicare help?

Let’s examine the different parts of Medicare, what they’re for, and what you need to know.

Medicare Part A

Medicare Part A was originally intended for hospital care, but under some circumstances can be applied to care in a skilled nursing facility. Among the services covered are a semi-private room, meals, nursing care, social services, dietary counseling, certain types of therapy, and medications.

However, the duration of coverage is limited to 100 days, with benefit payments disbursed on a duration-based sliding scale. Furthermore, the patient must assume all expenses past the one hundredth day.

Medicare Part B

Medicare Part B plans cover certain services like doctor visits, lab tests, and surgeries not covered under Medicare Part A (what most of us traditionally think of when we think of Medicare).

Broadly speaking, Medicare Part B covers two categories of medical services. These are medically necessary services (diagnostics and treatment) and preventive services (designed to prevent disease or detect it at an early and more treatable stage). There’s a wide range of coverage for inpatient and outpatient services, mental health services, durable medical equipment, and more. However, there can be a number of gaps and exceptions, so even Medicare Part B is not a guarantee of coverage.

Medicare Parts C and D

Medicare Part C, also known as Medicare Advantage, encompasses the same services as Parts A and B of Medicare, but is administered through a private company instead of being handled by the government. Medicare Part D simply adds prescription drug coverage.

How is Coverage Determined?

In brief, it’s complicated. More specifically, there are a number of federal and state laws governing Medicare coverage. Specific coverage decisions may be made at the national level, or by local companies charged with processing Medicare claims. In the case of Medicare Part C, the company handling your coverage may have additional policies and procedures in addition to their obligations under federal law.

Consult a Professional

Yes, we know this may seem confusing. Determining the kind of coverage you have is simple; it’s just a matter of checking your red, white, and blue Medicare card. Determining whether Medicare will cover your needs in a long-term care setting is much more complicated, and is often a conversation you’ll be having between your long-term care facility, your family, and your care providers. In certain circumstances, it’s also useful to enlist the services of a lawyer or financial planner.

As the largest and longest-serving dementia care unit in the state of West Virginia, Princeton Health Care Center has decades’ worth of experience helping families with long-term care for those they love. We invite you to contact us with your questions, especially those related to bearing the financial responsibilities of long-term care.

Note: The preceding are only guidelines and should not be construed as legal advice; for full details on your rights and responsibilities under Medicare, consult with Princeton Health Care Center or with an expert in elder care.


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