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By John M. Bigler Many of the decisions people make in planning for their old age are based on what they believe they know. Not all of these facts that people think they know are true. Some have elements of truth, but they need to be more fully understood. I would like to examine some of these items of accepted wisdom.
Reprinted with permission of the Suffolk Times © 2002
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While most people are aware that nursing homes are expensive, few know how expensive or have any idea about a specific cost. Nationally, the average cost of a month in a nursing home is over $4,500. As you might expect, the average cost in the metropolitan area is significantly higher. Suffolk County is probably the most expensive area in the country for nursing homes, with the average cost about $8,000 per month with some homes costing as much as $11,000 per month.
Many people expect Medicare to cover, or at least contribute to, the high cost of nursing home care should they ever need it. Medicare's help with nursing home costs is very limited. The Medicare program is restricted to assisting with payment for short-term nursing home care for those people who meet the criteria for skilled care. Medicare doesn't pay for any other kind of nursing home care.
Medicare does pay for short-term nursing home care in a skilled nursing facility for a period of no more than 100 days. From the 21st day of care onward, the patient is responsible for a copayment. After 100 days, neither Medicare nor a Medicare supplement will pay anything. Beginning with the 101st day, Medicare's contribution would end, with the patient being left responsible for all of the nursing home costs.
Even then, there are strict criteria for determining whether a nursing home stay and the care provided is medically necessary and covered by the program. Medicare only addresses acute and skilled medical problems of the elderly. It was designed to help pay for short-term treatments intended to restore an individual to full health. It is usually not available without a fight to help maintain a person throughout an illness where there is no prospect of a return to a life such as was enjoyed before the onset of illness.
Because the point of Medicare is to pay for the treatment necessary to cure a patient and not to provide ongoing care over an extended period of time, there are requirements about the kind of services are covered. The patient must have been in a hospital for at least three days before entering the skilled nursing facility, and must then be admitted to the nursing home within 30 days of being discharged from the hospital. A physician must prescribe the stay in an approved skilled nursing facility. Medicare will not pay for "intermediate care," or "custodial care".
Private supplementary Medicare insurance (Medigap) won't help lengthen the amount of time that benefits are paid. If Medicare doesn't cover treatment, Medigap insurance won't pay either. Medigap will only pay for a larger percentage of the total bill over the 100 days Medicare coverage was available.
Medicare will only pay for home care by a skilled nurse under strictly defined circumstances. A doctor must determine that the patient is unable to leave his home and that a skilled nurse is medically necessary to the patient's care in the home. Medigap will rarely cover skilled nursing care delivered in the home at all.
Neither Medicare nor Medicaid will contribute toward the cost of an assisted living facility. Practically speaking, then, Medicare does not help with the long-term costs of the nursing home for the typical older individual who wants or needs such care.