Coverage Limits of Long Term Care from Medicare and Private Health Insurance

Many families are in disbelief when a Skilled Nursing Facility Discharge Planner notifies them that they need to prepare for their loved one to come home because Medicare has not approved any more benefits.

As you can see, after day 100, Medicare does not pay for extended care.  If Medicare does not approve, then the Medicare Supplement does not kick in either.  On average, most patients are discharged within 20 days.

The below chart shows the most common types of insurance and the very limited long-term care coverage they provide.

Coverage Limits of Long-term care (LTC) Offered by Health Insurance

LTC Service Medicare Medigap Insurance Private Insurance
Overview Limited coverage for nursing home care following a hospital stay and home health if you require a nurse or other skilled provider Insurance purchased to cover Medicare cost sharing Varies, but generally only covers services for a short time following a hospital stay, surgery or while recovering from an injury
Nursing home care Pays in full for days 1–20 if you are in a Skilled Nursing Facility following a recent 3-day hospital stay. If your need for skilled care continues, may pay for the difference between the total daily cost and your copayment of $137.50 per day for days 21-100. After day 100 does not pay May cover the $137.50 per day copayment if your nursing home stay meets all other Medicare requirements Varies, but limited
Assisted living facility Does not pay Does not pay Does not pay
Continuing Care  retirement community Does not pay Does not pay Does not pay
Adult day services Not covered Not covered Not covered
Home care Limited to reasonable, necessary part-time or intermittent skilled nursing care and home health aide services, some therapies if a doctor orders them, and a Medicare-certified home health agency provides them. Does not pay for on-going personal care or only help with Activities of Daily Living (also called “custodial care”) Not covered under current policies. Some policies sold prior to 2009 offered an at-home recovery benefit that pays up to $1,600 per year for short-term at-home assistance with activities of daily living (bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury, or surgery Varies, but limited

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