Traditionally, Medicare hasn’t covered long-term care. And — spoiler alert — it still doesn’t. However, the rise of Medicare Advantage plans has opened a few doors that weren’t open before. While Medicare still doesn’t provide long-term care coverage — patients will have to subscribe to a different type of plan if they want that — it is beginning to provide coverage for certain aspects of long-term care.
So what “aspects” are we talking about?
What is the Difference Between Medicare and Medicare Advantage?
First, let’s dive into the difference between traditional Medicare (often referred to as Original Medicare) and Medicare Advantage. The first thing to understand is that Medicare Advantage, also known as Medicare Part C, is a private insurance plan. It replaces an individual’s Medicare Part A (hospital visits and inpatient care) AND Part B (physician appointments and outpatient care) with a plan from a private insurance provider. This plan must provide the same benefits as the Medicare plan it replaces. However, it also adds a lot of additional benefits not provided under Original Medicare.
What Types of Benefits Does Medicare Advantage Cover?
In addition to the benefits provided by Medicare Parts A and B, Medicare Advantage plans often offer dental, vision, and prescription drug coverage. Recently, insurance providers have expanded the coverage they offer to include benefits like meal delivery, home care services, rides to medical appointments, and home modifications like bathroom grab bars.
The benefits each plan offers varies based on the area it serves. In qualifying areas, Medicare Advantage plans can even cover grocery deliveries and transportation for non-medical needs for those with chronic illnesses. Some providers also offer options for gym memberships and fitness plans.
Are There Additional Costs with Medicare Advantage?
The cost of each Medicare Advantage plan depends on the plan itself. Most people who qualify for Medicare receive Part A benefits for free and pay a small monthly premium for Part B benefits. This is true for Medicare Advantage, as well. Some plans charge a monthly premium, while others do not. It all depends on which provider an individual chooses for their Medicare Advantage plan.
Custodial Care Vs. Skilled Care
Even with all the changes Medicare Advantage is bringing, it’s still limited in the kind of care it will cover in a long-term care environment. To understand what is covered and what isn’t, we must discuss the different types of care.
Medicare, along with most private insurance plans, pay for services that fall under “skilled care.” This includes medical services, rehabilitation, nursing, or medication administration. Medicare Advantage also covers specialized care, including stays in skilled nursing facilities, hospice care, and some home care services.
So what isn’t covered?
“Custodial care,” not typically covered by Medicare Advantage, includes services that are considered help with activities of daily living, or ADLs. These include eating, bathing, dressing, toileting, and other non-medical care. This is the type of care provided by most long-term care and assisted living facilities.
What Does This Mean for My Nursing Home?
Unless you have a contract with a Medicare Advantage insurance provider, Medicare Advantage will not cover most of the services your nursing home provides for long-term care. Stays in skilled nursing facilities and nursing homes are covered up to the first 100 days (though plans require coinsurance beyond 20 days). After that, residents are on their own. The plans should cover prescription medications and any therapies provided by your facility, however.
For nursing homes, the real benefit of Medicare Advantage is the coverage of prescription medications. Under Original Medicare, medications were not covered unless the resident was under a Part A stay. For many residents, that's a game changer.
While Medicare still doesn’t cover long-term care, the recent expansion of benefits under Medicare Advantage indicate that relief is on the way — and options could be opening up in the future.