Medicare Advantage Plans Closer to Covering Long-Term Care

The Centers for Medicare & Medicaid Services announced in May that Medicare Advantage plans can expand their coverage of supplemental benefits. Starting in 2019, Medicare Advantage plans will be able to offer coverage of services like respite care, non-hospice palliative care or home safety modifications. Industry experts are saying this can move Medicare Advantage closer to covering long-term residential care one day.

A major downside of Medicare as it’s currently formulated is that it doesn’t cover custodial long-term care. That means if a senior doesn’t need specific skilled nursing care, but can no longer live on their own, they either need to pay for the facility out of pocket, or exhaust all their assets to go on Medicaid. Paying for long-term care is a huge financial burden on many seniors who aren’t eligible for Medicaid. The new rules will allow Medicare Advantage plans to cover in-home support services, like help with activities of daily living. Such coverage may one day lead to coverage of non-skilled nursing facility stays.

How Big is This Change Exactly?

While the changes will probably be modest in the beginning, the paradigm shift is huge. Until now, Medicare Advantage plans mainly covered whatever Original Medicare covered, with some additions like dental or vision coverage. Now, in an attempt to save more in preventable medical expenses in the long run, they will have an expanded definition of “health-related” services. The new guidelines, according to CMS, will “consider an item or service as primarily health related if it is used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and health care utilization.”

This opens the door for long-term care services to gain coverage under CMS. In the beginning it may cover home-health services, and then it may eventually expand to cover some nursing home expenses.

Of course, these services will be subject to restrictions and requirements for coverage. Your doctor or other healthcare provider would have to recommend the service, and there will likely be copious paperwork. It’s also likely that the Medicare Advantage plans will decide eligibility for specific services based on the member’s medical needs and history. Either way, the program expansion is great news for Medicare Advantage members, and will probably increase the private plans’ share of the Medicare market.

Here are some services you can expect to see covered next year:


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