What is Medicare and what does it cover?
Medicare pays for health care for:
- People age 65 years and older
- People under age 65 with receiving Social Security Disability benefits
- People of all ages diagnosed with Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's disease) or end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).
Medicare covers medically necessary care for acute care, such as doctor visits, drugs, and hospital stays.
Except for the specific circumstances described below, Medicare does not pay for most long-term care services or personal care— such as help with bathing or for supervision (often referred to as custodial care).
When Does Medicare Pay for Long-term Care Services?
Medicare will help pay for a short stay in a skilled nursing facility if you meet all of the following conditions:
- You have had a hospital admission with an inpatient stay of at least three days
- You are admitted to a Medicare-certified nursing facility within 30 daysof that inpatient hospital stay
- You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy
If you meet all these conditions, Original Medicare will pay a portion of the costs for up to 100 days for each benefit period as follows:
- For the first 20 days, Medicare pays 100 percent of the cost.
- For days 21 through 100, you pay a daily copayment, which was $164.50 as of November 2017), and Medicare pays any balance.
- Medicare does not pay costs for days you stay in a skilled nursing facility after day 100.
(Medicare Advantage plans must cover the same services, but the cost sharing may vary.)
To treat medical conditions
Medicare pays for the following services when your doctor prescribes them as medically necessary to treat an illness or injury:
- Part-time or intermittent skilled nursing care
- Physical therapy, occupational therapy, and speech-language pathology provided by a Medicare-certified home health agency.
- Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding your disease
- Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, Medicare pays 80 percent of approved amount and you pay 20 percent.
There is no limit on how long you can receive any of these services as long as they remain medically necessary and a doctor reorders them every 60 days. There also is no requirement for your condition to improve, or for improvement to be expected.
To prevent further decline due to medical conditions
In some cases, Medicare also covers ongoing long-term care services to prevent further decline for people with medical conditions that may not improve. This can include conditions like stroke, Parkinson's disease, ALS, Multiple Sclerosis, or Alzheimer's disease.
Medicare covers hospice care if you have a terminal illness, are no longer seeking a cure, and you are not expected to live more than six months. With hospice care, Medicare covers drugs to control symptoms of the illness and pain relief, medical and support services from a Medicare-approved hospice provider, limited respite care, and other services that Medicare does not otherwise cover, such as grief counseling. You may receive hospice care in your home, in a nursing home, or in a hospice care facility. Medicare also pays for some short-term hospital stays and inpatient care for caregiver respite.