Medicare Rules for Long-Term Care

Medicare is a government insurance policy mostly for citizens 65 years or older. Given the age range of the average Medicare recipient, long-term care issues are important. Medicare's benefits are generous, but these are governed by strict, albeit general, rules that must be followed under most circumstances.

Part A

• The long-term rules are found in Part A of the Medicare system. This is the general "hospitalization" aspect of Medicare, and it is the "automatic" part that begins on the first of the month that you turn 65. Most people get Part A for free, but some, those who have not worked regularly and have not paid payroll taxes, must buy it. For part A by itself, there is a flat $450 charge per month for everyone.

Hospital Rules

• If you require blood transfusions, you get it free if the hospital does. If the hospital needs to pay for the blood, you must pay for the first three units. For hospital stays that last more than three days, Medicare covers most of this so long as your doctor authorizes it. Medicare will not pay for a private room or any "extras" like television or phone service. Medicare will pay for any skilled, long-term nursing care so long as it is a proven medical necessity.

Injury Rules

• If you have had an injury that caused a three-day hospital stay at minimum, Medicare will pay for all long-term medical expenses that derive from that. For all long-term Medicare payments, a doctor must certify all aspects of your long-term care. Medicare will not pay for anything long term that has not been verified by a doctor that is himself approved by the Medicare system.

Home Health Rules

• Medicare covers home health care so long as it is both directly medical and approved in advance by your doctor. All forms of medical therapy including speech and physical therapy are covered. You must prove, through your doctor's examination, that you are homebound. If you cannot prove this, you will not be covered for most home health care, though your doctor might recommend certain treatments in the home as a matter of necessity. Part A will never, under any circumstances, cover what is called "custodial care." This refers to non-medical care in the home such as basic cooking, laundry and dressing services. Medicare will only cover skilled medical care. Medicare will never cover "private duty" nursing care either.

Hospice Rules

• Hospice care is given by skilled medical technicians for those who are terminally ill. To qualify for Medicare hospice care, you must prove that you will live less than six months from the date of your request. If you have the misfortune of living longer than that, there may be penalties assessed. Generally, what Medicare will pay for under hospice care is pain regulation and short-term hospital stays for pain management and similar issues that are pre-approved by your doctor.