Who Pays for Long-Term Care?

Private Individuals

Most long-term care is paid for by the people receiving the care or by their families. Other sources of payment include Medicaid (Medical Assistance), Medicare, veterans' payments, and private insurance. Many individuals who require extensive long-term care eventually "spend-down" their savings and other resources and become eligible for Medicaid.

Medicare

Medicare is the federal program that helps pay hospital and medical costs for those who are 65 or older and some disabled persons. It provides very limited coverage for short periods of time for nursing home and home health care but does not cover any long-term care services for extended periods of time.

Nursing Home Care

If a nursing home stay is approved by Medicare, then Medicare pays in full for up to 20 days of skilled nursing care in a skilled nursing facility approved by Medicare. However, Medicare will pay for your stay only if it follows a hospitalization of at least 3 days and you enter a Medicare-certified nursing home within 30 days after hospital discharge. From the 21st to the 100th day, Medicare pays part of the cost if the stay is still approved by Medicare. Medicare pays nothing beyond the 100th day. Very few nursing home stays are covered by Medicare. This is both because many nursing homes do not participate in the Medicare program and because Medicare defines "skilled care" in a very restrictive way.

Home Health Care

Medicare covers only those home health care visits that Medicare considers to be medically necessary. Medically necessary care is defined quite narrowly and you must meet certain other criteria before Medicare will pay for the care. For example:

  • The care must include part-time skilled nursing care, physical therapy, or speech therapy;
  • You must be confined to home;
  • Your doctor must set up a home health plan; and
  • The agency providing services must participate in Medicare.

Most home health care visits do not meet Medicare's definition of medically necessary care. Therefore, Medicare will not pay for them.

Medicaid

Medicaid, also known as Medical Assistance or Title XIX, is a government health care program paid for by state and federal governments. To be eligible for Medicaid:

  • You must be 65 or over, or disabled, or in a family with dependent children;
    and
  • You must have low income and few assets; or
  • You must be paying so much money for health care that you have very little income left.

If you are eligible, Medicaid pays for most health care costs, including nursing home and community-based care.

Nursing Home Care

Medicaid is a major source of payment for nursing home care. About 64% of all nursing home residents in Wisconsin receive help with their nursing home costs. To qualify for Medicaid nursing home benefits, you must require medical, nursing, and/or therapeutic care on a daily basis, and be under a doctor's plan of treatment. Even if you become eligible for Medicaid, most of your income must be used to pay nursing home bills, with Medicaid paying remaining costs. (Wisconsin Department of Health Services).

When first admitted, many residents of nursing homes are able to pay for their care themselves. Over the course of a long nursing home stay, many people use most of their savings to pay for their care and then become eligible for Medicaid.

Home Health Care

Medicaid may pay for services you receive in your home. However, you must be under a doctor's plan of care, have medical needs that can be met in your own home, and receive services from a home health care agency certified by Medicaid.

Personal Care

Medicaid also pays for personal care, such as assistance with bathing, dressing, eating, or getting in and out of bed. To be paid by Medicaid, you must be under a doctor's plan of care and you must receive services from a personal care agency certified by Medicaid. You may also be eligible for a limited amount of necessary household help, such as grocery shopping, meal preparation, or laundry.

Community Options Program

In Wisconsin, the Community Options Program (COP) provides community-based long-term care services to some individuals who would otherwise need nursing home care. If you qualify based on limited income and assets, all or part of the cost of the care can be paid by a special state funding program or, in some cases, Medicaid. The COP offers a wide range of services including personal care, respite care, adult day care, transportation, and even necessary help with household chores. Information on eligibility for the COP may be obtained from your local county aging unit or your local county social or human services department.

SPOUSAL IMPOVERISHMENT PROTECTIONS

If you are married and have a spouse who is receiving long-term care in a nursing home, the law permits you to keep a certain amount of monthly income and retain a certain amount of assets even if your spouse's long-term care costs are being paid by Medicaid. The amount you are allowed to retain is in addition to the family home and other noncounted assets. You may obtain more information on-line at www.dhs.wisconsin.gov/Medicaid/publications/p-10063.htm or by contacting your county or tribal aging office (www.dhs.wisconsin.gov/aging/contacts/coagof.htm).

You may want to consider consulting with your local county or tribal aging office or an elder law attorney if you are considering a "Medicaid-friendly" annuity to qualify for Medicaid.


Estate Recovery Program

Wisconsin has an estate recovery program through which the state seeks repayment of Medicaid payments for care received while the recipient resided in a nursing home. The program also seeks recovery of certain noninstitutional Medicaid benefits for recipients over age 55. The recovery is made from the estate of a recipient's spouse. An estate includes all assets owned by a person at the time of death.

More information about the Estate Recovery Program is available from your county or tribal aging office (www.dhs.wisconsin.gov/aging/contacts/COAGOF.HTM).

Medicare Supplement Insurance

Medicare supplement insurance policies do not provide coverage for long-term care. They are designed to supplement Medicare and provide very limited coverage for nursing home and home health care. For more information on the benefits included in Medicare supplement insurance policies, consult the booklet Wisconsin Guide to Health Insurance for People with Medicare which is available from the Office of the Commissioner of Insurance.