Long Term Care Planning: What’s Covered, and What Isn’t

We were invited to write a series of brief articles for the monthly newsletter of our friends at MDK Insurance Services, describing the continuum of long term care, and how to navigate oneself through it. You can sign up for the newsletter on their website, and each month we provide a copy of the article here as well. Please share the information with someone you know who is thinking ahead about how to plan for (and pay for) their own or a loved one’s long term care.

Volume VIII: What’s Covered, and What Isn’tIn previous issues, we’ve described the various settings in which long term careis provided, often referred to as the “continuum of care.” Many are caught off guard in the midst of a health care crisis by a sudden and surprising lesson inwhich types of care are covered by Medicare or other forms of health insurance, and which require private payment.The simplest way to understand whether a particular type of care will be covered is generally this: if a physician orders it, it requires the services of a licensed healthcare provider, and its goal is to treat an acute condition, then Medicare or health insurance will cover at least a portion of its cost. If those conditions are not met, then it is not covered.

Care provided within a skilled nursing facility (SNF) is frequently an area of confusion. Up to 100 days of a short-term rehabilitative stay in a SNF while recovering from an acute illness or injury after a hospitalization will in large part be covered by Medicare, but long-term “custodial” care for an individual who requires assistance with daily tasks that cannot be provided within other settings is not, and must be paid for privately. Home health care (licensed nursing or therapy services provided on a short-term basis for rehabilitative purposes) is generally a covered health insurance/Medicare benefit, as is hospice care.

Care provided within residential care facilities, including assisted living apartments, board and care homes, continuing care retirement communities, and residential dementia care, is not covered by Medicare or other health insurance. Non-medical home care services are also not covered; this includes services to assist with activities of daily living such as bathing, toileting, and ambulating, and is often referred to as “custodial” or “private duty” care. Professional services such as those provided by a geriatric care manager or fiduciary require private payment, as do most community-based adult day programs and transportation services. These “non-medical” settings are where the majority of long term care services are provided, so thoughtful planning about how they will be financed is essential.

Next month we’ll wrap up this series with a look at the costs of long term care, and tips for developing a personal plan.