Many people expect Medicare to pay for their long-term care. Unfortunately, Medicare only pays for medically necessary skilled care, and then only after some stringent conditions are met. The vast majority of people who need long-term care may not need skilled care -although they might need someone to look after them and to help them with the activities of daily living. Looking at national averages, Medicare only pays for 12% of people in skilled nursing facilities (House Committee onWays and Means 2007 .
However, even this small percentage is only for people who need skilled care. What about those who need custodial care? And what's the difference between the two
What is skilled care?
First, people who require skilled medical care are often suffering from an illness or injury. On the other hand, folks who need custodial care are usually recovering from an illness or injury, or experiencing problems with performing activities of daily living that come from advancing age.
Next, skilled care must be given by a medical professional. Custodial care is given by a trained professional, family member, or other caregiver.
Finally, skilled care is rarely needed following discharge from the hospital. If you break your hip and spend five days in the hospital, you have met part of the Medicare requirement for nursing home care coverage. However, while you may need assistance with activities of daily living such as dressing, transferring, and bathing, almost anyone can provide this help. And you probably don't need to be in a nursing home to get the care you need.
Thus, Medicare will usually not pay in this case.
This same result can happen if you have a stroke since you may not need skilled care in a nursing home. You may need nursing home assistance, but the care you require is custodial—assistance with activities of daily living.
Over-reliance on Medicare is a mistake many seniors and their families simply cannot afford to make.