Many consumers and policymakers mistakenly believe that Medicare – the federal health insurance program for people age 65 and older and some younger people with disabilities – pays for long-term care. It does not, as stated in the official Medicare handbook. Millions of Medicare enrollees must pay for long-term care services (such as personal assistance at home, assisted living, and nursing home care) entirely from their own income and savings.
Confusion often stems from misinterpretation of coverage provided by Medicare’s “post-acute” home health care and skilled nursing facility benefits. Post-acute services focus on medically related skilled nursing and therapy services some patients need after hospital or outpatient treatment. Examples include skilled nursing visits for wound care and physical therapy after hip surgery. In contrast, long-term care (also called long-term services and supports) consists mainly of personal assistance with routine activities such as bathing, using the toilet and managing medications, for individuals who need this assistance because of ongoing functional limitations (usually defined as lasting three months or longer).
While post-acute care and long-term care are distinct, the same types of providers – home health agencies and skilled nursing facilities – offer both types of care, contributing to the confusion. A closer look at Medicare’s benefits and data on use make clear Medicare’s post-acute focus.
Medicare’s home health care benefit pays for intermittent skilled nursing and therapy visits for people who are homebound and have a doctor-certified medical need for services. The argument that the home health benefit pays for long-term care focuses on home health aide visits, which can provide some personal assistance to people eligible for skilled visits. But coverage of these aide visits is limited, and data reveal they are a small part of the overall home health program. Only 17 percent of Medicare home health visits, accounting for about 11 percent of home health spending, are aide visits – and a significant portion of these visits go to people with temporary, not long-term, needs for personal assistance.
Medicare covers up to 100 days of skilled nursing facility care, but only after a hospital stay of at least three days and only for people with a daily need for skilled care, such as intravenous injections or physical therapy. Some critics contend that providers game the system so that Medicare inappropriately pays for personal care days. But data show that the overwhelming majority of Medicare-financed skilled nursing facility stays are much shorter than they would be if providers “maximized” Medicare to pay for long-term care: Ninety percent of Medicare-covered skilled nursing facility stays are for 60 or fewer days, and over half (52 percent) are 20 or fewer days.
Clearing up this misperception about Medicare is crucial: First, Americans need to understand the limits of Medicare coverage as they make decisions about long-term care. Second, policy leaders, including the Commission on Long-Term Care, need an accurate picture of how long-term care is financed. The commission should be clear that most Medicare enrollees, like most Americans, have no insurance protection for long-term care.
Harriet Komisar, Ph.D., is a senior strategic policy adviser at the AARP Public Policy Institute, where she works on Medicare and other health care topics.