A recent study from Nationwide sheds light on where clients think Medicare fits into long-term care: 58% of those surveyed believe that Medicare pays for long-term care.
This assumption is one of the most common (and dangerous) misconceptions among retirees and pre-retirees. Educating clients about what Medicare does and doesn’t cover is essential to helping them make informed choices about long-term care (LTC) planning.
Here’s how to break it down:
What Medicare Covers
Medicare is designed to cover limited, medically necessary care, not ongoing custodial care. Here’s what it does cover in terms of LTC-related services:
1. Skilled Nursing Facility (SNF) Care
- Must follow a 3-day inpatient hospital stay
- Medicare pays 100% of the first 20 days
- For days 21–100, the patient pays a daily copayment ($209.50/day in 2025).
- After day 100, Medicare pays $0.
- Services must be for rehabilitation or skilled nursing, not custodial care.
2. Home Health Care
- Covered if the patient is homebound and needs intermittent skilled care (nursing or therapy)
- Does not cover ongoing personal care (bathing, dressing, etc.) without a skilled component
3. Hospice Care
- Covered if the patient is terminally ill with a life expectancy of 6 months or less
- Focuses on comfort care, not curative treatment
- Important to note: if receiving hospice care at home, hospice does not provide 24/7 home care. Rather, they provide intermittent care that subsidizes the care administered by family or a paid home health care agency. This amounts to a few short follow-ups per week.
What Medicare Does Not Cover
Here’s where the gap becomes painfully clear:
- Long-term nursing home stays beyond 100 days
- Assisted living facilities
- Custodial home care if no skilled services are needed
- Adult day care, memory care, or private caregivers (unless part of a skilled plan)
- 24/7 Hospice care at home
Medicare is not a safety net. It was never designed for the rising demand of long-term care needs.
Explaining Medicare and LTC With Clients
Here’s a simple way to explain Medicare’s role in long-term care to clients:
“Medicare covers limited care after a hospital stay but it doesn’t pay for help with daily activities like bathing, dressing, or living in an assisted living facility. That’s where long-term care planning becomes critical.”
You can then transition into options: traditional LTCI, hybrid life/LTC policies, annuities with LTC riders, short-term care insurance, or even self-funding strategies, depending on which option best suits their situation.
Protecting Clients from the Unknown
We owe it to our clients to correct the Medicare myth early, before a care crisis hits. Helping them understand the limits of government programs not only builds trust but positions you as a true advisor, not just a policy pusher.
Next Steps for Agents
- Include Medicare limitations in your LTC presentations.
- Create visual breakdowns of what Medicare covers vs. what it doesn’t.
- Use real claims examples (anonymously) to highlight the gaps.
- Offer policy reviews to identify risk exposure in current coverage.
Medicare is not a long-term care solution. It’s a piece of the healthcare puzzle—not the whole picture. Let’s help our clients see the full picture before the need for care forces them to.