About 70% of adults turning 65 will need some form of long-term care in their lifetime, according to the U.S. Department of Health and Human Services. Medicare covers up to 100 days of skilled nursing care per benefit period, but the average Medicare-covered stay is far shorter. And Medicaid is the single largest payer of long-term care in the United States, covering roughly 58% of long-term services and supports spending and serving as the primary payer for over 6 in 10 nursing facility residents, per the Kaiser Family Foundation.
Knowing which program pays for what is the first step to a plan that protects the family.
A retired teacher in Vero Beach assumed Medicare would pay for her long-term care, and her family assumed the same. This is a composite example drawn from the many families I have helped, not one real client, but it is the story I hear most often.
After a hip replacement she spent 18 days in a rehab facility that Medicare covered, and the family was relieved. The care was skilled, it was short-term, and Medicare paid its share. But when she came home and needed ongoing help with daily tasks like bathing, dressing, and meals, they learned Medicare does not cover that kind of custodial help. The relief turned to worry, and the family had to figure out the real options, which is exactly what this chapter walks through.
I have sat at kitchen tables from the Treasure Coast to South Florida long enough to know that moment, when a family realizes the program they counted on does not cover the care that has actually arrived. As a Certified Real Estate Planning Advisor and The Life Transition Specialist, my job is to walk families through Medicare and Medicaid before the crisis, not after, so the plan is in place long before anyone needs a bed.
This companion post covers the same ground as Chapter 8 of my book, How to Pay for Long-Term Care , in a few minutes of reading: what Medicare covers, what Medicaid covers, the honest truth about spending down, and how to apply for each. If you are just joining the series, Chapter 1, The Facts , is the place to start.
01 · Answer First
What Is the Difference Between Medicare and Medicaid for Long-Term Care?
Medicare is a federal health program for people 65 and older that covers limited skilled care, such as up to 100 days in a skilled nursing facility after a hospital stay and short-term home health, but it does not cover most long-term custodial care.
Medicaid is a joint federal and state program for people with limited income and assets that is the single largest payer of long-term care in the United States, covering nursing home care and, in many states, home and community-based services. The short version: Medicare is for everyone 65 and older and covers skilled care for a limited time, while Medicaid is for people who qualify as financially limited and is the program that actually pays for most long-term care.
02 · Medicare
What Medicare Covers
Medicare is the health insurance most seniors already have, and it is built around four parts. Everyone on Medicare gets the same basic benefits, whether they are on Original Medicare or a Medicare Advantage plan, and those benefits are:
- Part A, hospital insurance: helps pay for inpatient hospital care, limited skilled nursing facility stays following a hospital stay, some in-home health care, and hospice.
- Part B, medical insurance: helps pay for doctors, outpatient care, home health care, durable medical equipment, and some preventive services.
- Part D, prescription drug coverage: helps pay for prescription medications.
- Medigap supplemental policies: help pay out-of-pocket copayments, coinsurance, and deductibles, but they do not cover long-term care.
Here is the part families miss. Medicare only pays for long-term care when skilled or rehabilitative services are required, for a maximum of 100 days in a nursing home, and generally only for a short period. It does not cover assistance with Activities of Daily Living (ADLs), the help with bathing, dressing, eating, and using the bathroom that makes up most long-term care. That is the gap the retired teacher in Vero Beach ran straight into, and it is the gap this chapter exists to close.
03 · Medicaid
What Medicaid Covers
Medicaid is jointly funded by the federal and state governments and is the single largest payer of long-term care in the United States. It offers extensive long-term care benefits, but only for those who qualify as financially limited, which is why it is often called the safety net.
The benefits vary by state, but every state must pay for nursing home care and for home health care for those who would need a nursing home without it. An increasing number of states also cover home and community-based services, including personal care, adult day care, homemaker services, and therapy, while only a few pay for assisted living, and generally only for the care services, not room and board. Medicaid covers nursing home care only in a Medicaid-certified facility, and most, but not all, nursing homes are certified.
The Honest Truth About Spending Down
Some people who are not poor when they first need long-term care eventually rely on Medicaid after spending nearly all their assets and income on care. That is called spending down, and it does work, but it comes with significant drawbacks. It leaves a person with extremely limited assets and income and the loss of financial independence. Assets cannot be left to heirs or used for purposes like helping grandchildren with college. The types of care available are often limited, and home and community-based services are not offered everywhere. Medicaid recipients also often have a more limited choice of facilities, with the most desirable communities often not accepting Medicaid, longer waiting lists, and the possibility of being placed far from family and friends.
04 · How to Apply
How to Apply for Medicare
Social Security automatically enrolls most people in Original Medicare Part A and Part B. Most people 65 or older qualify for premium-free Part A if they worked and paid Medicare taxes, while Part B requires a monthly premium.
- The initial enrollment period begins three months before the 65th birthday, includes the birthday month, and ends three months after.
- Delaying Part B can raise the monthly premium by 10% for each 12-month period you were eligible but did not enroll.
- A general enrollment period runs January 1 through March 31, with coverage starting July 1.
- People can choose Original Medicare plus a Medigap policy, which helps with out-of-pocket costs but never covers long-term care.
05 · How to Apply
How to Apply for Medicaid
Each state runs its own Medicaid program. Contact the local Medicaid office to apply in person, by phone, or online, or designate a family member or an elder law attorney to apply for you. Some states require a face-to-face interview.
You will need an application form and documentation to verify general and financial requirements, then a functional eligibility assessment for long-term care services. If you own a home, you may need the fair market value, current tax bill, real estate appraisal, and mortgage documents. Many states also accept applications at Aging and Disability Resource Centers (ADRCs), which can walk a family through the paperwork step by step.
06 · Keep in Mind
Red Flags and Keep in Mind
The mistakes I see most often are the ones that are easiest to avoid once you know them. Watch for these:
- Assuming Medicare will cover long-term care. It covers limited skilled care for a short time, not the everyday custodial help most families need.
- Believing Medigap covers long-term care. Medigap helps with copayments, coinsurance, and deductibles, but it does not cover long-term care.
- Waiting until a crisis to plan. The best plans are built while everyone is healthy, with time to compare options and protect assets.
- Spending down without understanding the loss of assets and independence. Medicaid works, but it changes what you can leave to family and where you can receive care.
- Not checking whether a facility accepts Medicaid before choosing it. Most, but not all, nursing homes are Medicaid-certified, and the most desirable communities often do not accept Medicaid at all.
Quick Answers
Questions Families Ask About Medicare and Medicaid
Generally, no. Medicare pays for short-term, medically necessary skilled care after a hospital stay, but it does not cover long-term custodial care, the everyday help with bathing, dressing, and eating that most people mean by long-term care. After a qualifying hospital stay, Medicare Part A covers up to 100 days in a skilled nursing facility, with a daily coinsurance from day 21 on. The rest of the cost falls to you unless you have other coverage or assets.
Medicare is a federal health program for people 65 and older that covers limited skilled care, such as up to 100 days in a skilled nursing facility after a hospital stay and short-term home health, but does not cover most long-term custodial care. Medicaid is a joint federal and state program for people with limited income and assets that is the single largest payer of long-term care in the United States, covering nursing home care and, in many states, home and community-based services.
Medicare Part A covers up to 100 days in a skilled nursing facility per benefit period after a qualifying hospital stay of at least three days. The average covered stay is far shorter, and Medicare only pays when skilled or rehabilitative services are required. From day 21 through day 100, you pay a daily coinsurance amount.
No. Medicare does not cover custodial care, the help with Activities of Daily Living like bathing, dressing, eating, and using the bathroom that makes up most long-term care. Medicare covers skilled care, such as nursing and therapy after a hospital stay, but not the everyday personal care most families mean when they say long-term care.
Spending down means using nearly all of your income and assets on care until you meet Medicaid's financial limits and qualify. Many people who are not poor when they first need care eventually rely on Medicaid this way, but it leaves you with extremely limited assets and income, limits the care options and facilities available to you, and means assets cannot be left to heirs.
Each state runs its own Medicaid program. Contact your local Medicaid office to apply in person, by phone, or online, or designate a family member or elder law attorney to apply for you. You will need an application form and documentation to verify general and financial requirements, followed by a functional eligibility assessment for long-term care services. Many states also accept applications at Aging and Disability Resource Centers (ADRCs).
Yes. People who qualify for both are called dual eligible. Medicare is the primary payer for covered services, and Medicaid can help with premiums, copayments, and services Medicare does not cover, including long-term care for those who qualify. This combination is common for seniors who have Medicare and later spend down to Medicaid eligibility.
Medicare and Medicaid are the two programs at the center of every long-term care plan. Read Chapter 8 in full on the book hub, start the series with Chapter 1, The Facts , or browse the whole blog for more on senior transitions and paying for care.
About the Author
Michael "Wiz" Wisniewski
Michael "Wiz" Wisniewski is The Life Transition Specialist with The Complete Real Estate Team, powered by Dalton Wade Real Estate, serving clients from the Treasure Coast to South Florida. A Certified Real Estate Planning Advisor, Certified Life Transition Specialist, and Certified A.I. Real Estate Advisor, he has worked nearly every side of real estate: fix-and-flip investing, land development, home building, and property management, and guides families through life's transitions with care, honesty, and the Golden Rule.
Certified Real Estate Planning Advisor | Certified Life Transition Specialist | Certified A.I. Real Estate Advisor
The families who understand Medicare and Medicaid are the families who plan, and the families who plan are the families who never panic.
Plan Ahead, Protect the Family
Let’s plan ahead for long-term care with Michael
Michael Wisniewski, The Wizard of Real Estate and Life Transition Specialist with The Complete Real Estate Team powered by Dalton Wade Real Estate, helps Florida families from the Treasure Coast to South Florida understand Medicare and Medicaid before the crisis arrives. Book your free 15-minute strategy call, or call him directly at (561) 441-8420 .
Prefer to read first? How to Pay for Long-Term Care is free on our website, and Chapter 8 on Medicare and Medicaid lays out the whole picture. Have a specific question? Contact Michael directly.
If your family is facing Medicare and Medicaid, you do not have to guess.
Written by
Michael Wisniewski, The Wizard of Real Estate
Certified Real Estate Planning Advisor | Certified Life Transition Specialist | Certified A.I. Real Estate Advisor
Helping Florida families protect what matters most.
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