Medicare does NOT pay for long-term nursing home care. Many families assume it will. It won't. Medicare only covers short-term skilled nursing after a hospitalization. For long-term care, options are: pay privately ($8,000-15,000/month), have long-term care insurance, or qualify for Medicaid.
Medicare Explained: The Parts
Part A: Hospital Insurance
Covers inpatient hospital stays, skilled nursing facility (short-term), hospice, some home health. Usually premium-free if you paid Medicare taxes while working.
Part B: Medical Insurance
Covers doctor visits, outpatient care, preventive services, durable medical equipment. Monthly premium (about $175/month in 2024, deducted from Social Security). 20% copay after deductible.
Part C: Medicare Advantage
Private insurance that combines Parts A & B (and usually D). Often includes extra benefits (dental, vision, hearing). May have lower costs but restricted networks. Alternative to Original Medicare.
Part D: Prescription Drug Coverage
Covers prescription medications. Separate monthly premium (varies by plan). Has a "donut hole" coverage gap. Must sign up during enrollment periods or face penalties.
Medigap (Medicare Supplement) Plans
If your parent has Original Medicare (Parts A & B), they can buy a Medigap policy from a private insurer to cover copays, deductibles, and other gaps. Helps with that 20% copay Part B doesn't cover. Cannot have Medigap with Medicare Advantage.
Medicaid Explained
The safety net for long-term care
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Who Qualifies for Medicaid?
Requirements vary by state, but generally:
Income: Usually below ~$2,800/month for individuals (varies by state)
Assets: Usually below $2,000 in countable assets (home usually exempt while living in it)
Need: Must need nursing-home level of care (even for home care programs)
Note: Many people who weren't previously low-income become eligible after they "spend down" assets on care. This is where Medicaid planning comes in.
The 5-Year Look-Back Rule
When applying for Medicaid, the state looks at financial transactions for the past 5 years. Giving away money or assets during this period can result in a penalty period where Medicaid won't pay for care. Don't give away assets without consulting an elder law attorney first.
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What Medicaid Covers (That Medicare Doesn't)
Long-term nursing home care: The main reason people apply
Home and community-based services: Aides, adult day programs, modifications
Personal care assistance: Help with bathing, dressing, daily activities
Some dental, vision, hearing: Varies by state
Dual Eligible: Having Both
Many seniors have BOTH Medicare and Medicaid ("dual eligible"). Medicare is primary for medical care; Medicaid helps with costs Medicare doesn't cover and pays for long-term care. If your parent qualifies for both, they pay very little out of pocket.
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When to Consult an Elder Law Attorney
Your parent may need nursing home care in the next 5 years
They have a home or assets to protect
A spouse will remain at home while the other needs care
You're confused about spend-down strategies
They've been denied Medicaid and you want to appeal
You want to set up a Medicaid-compliant trust
Cost: $300-500/hour, but can save tens of thousands in preserved assets.
Key Contacts
Medicare: 1-800-MEDICARE (1-800-633-4227) or medicare.gov
Medicaid: Contact your state Medicaid office (search "[State] Medicaid")
SHIP: Free Medicare counseling in every state (shiphelp.org)
Benefits checkup: benefitscheckup.org (find all benefits they may qualify for)
Common Misconceptions
"Medicare covers nursing homes": Only short-term skilled care after hospitalization (up to 100 days, with copays after day 20)
"I have to lose everything before Medicaid helps": Spouses have protections; proper planning helps
"Medicaid takes the house": The home is usually exempt while you or your spouse lives in it, but estate recovery may apply after death
"Medicare Advantage is always better": Depends on your needs; network restrictions matter