Introduction: Ben and Sally were retired
and looking forward to their golden years. They had faithfully put
away enough that, when added to their social security and retirement
pension, would allow them to live comfortably, although not
extravagantly. They were 5 years into their retirement when disaster
hit! Ben had a stroke. It was a significant one. He could no longer
walk or feed himself and he had trouble talking. After the hospital,
Ben spent several months at the skilled nursing facility (SNF) for
rehabilitation. The medical personnel did all they could as did the
rehabilitation staff. In the end, walking, talking, and feeding
himself were just not going to be on the agenda for Ben. So now,
after the SNF, Ben is an an Assisted Living Facility (ALF). How is
Sally going to manage financially?
Needing Long Term Care: Over the years I have had a lot of Ben's
and Sally's in some form or another. Trust me when I say, these
things really do occur.
US Department of Health and Human Services tells us that "people
who reach age 65 will likely have a 40 percent chance of entering a
nursing home. About 10 percent of the people who enter a nursing
home will stay there five years or more.....” And
Medicare tells us that “This year, about nine million men and
women over the age of 65 will need long term care. By 2020, 12
million older Americans will need long term care. Most will be cared
for at home; family and friends are the sole caregivers for 70
percent of the elderly".
Medicare: So what does Medicare pay for when
it comes to this type of care. The government website states as
follows: "Generally, Medicare doesn’t pay for long-term care.
Medicare pays only for medically necessary skilled nursing facility
or home health care. However, you must meet certain conditions for
Medicare to pay for these types of care. Most long-term care is to
assist people with support services such as activities of daily
living like dressing, bathing, and using the bathroom. Medicare
doesn’t pay for this type of care called "custodial care". Custodial
care (non-skilled care) is care that helps you with activities of
daily living. It may also include care that most people do for
themselves, for example, diabetes monitoring. Some Medicare
Advantage Plans (formerly Medicare + Choice) may offer limited
skilled nursing facility and home care (skilled care) coverage if
the care is medically necessary."
Further, you will find that even if we are talking about skilled
nursing care as opposed to custodial care,
Medicare generally will pay a maximum of only 100 days.* (See
page 13) That 100 days comes with several limitations. One of the
most important is that, generally, you enter the SNF within 30 days
of at least a 3 day stay at a hospital. (See page 14) Typically, we
say that anything in excess of the period for which Medicare will
pay is what we call “Long Term Care.” In other words, Medicare is
“short term care.”
What other programs are available for long term care?
Medi-Cal is a joint Federal-State program. It is referred to as
Medicaid in most of the rest of the country. The rules are different
in each state so what applies in California (the perspective from
which I am writing this article) may or may not govern elsewhere. It
pays for a SNF. It rarely pays for in-home-care or an ALF. The
program is extremely discriminatory. Many people would say if you
are rich, you don’t need Medi-Cal and if you are poor, you almost
But if you are of the middle class you must use some of the various
techniques to qualify.
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*The 100 day maximum can be reinstated once you are out of the
hospital or SNF for at least 60 days and in a few other limited