Skilled vs Long-Term Care: Do you know the difference?

When it comes to understanding healthcare people are often confused and misunderstand which services are covered by medical insurance and which are not. This is particularly so when we talk about skilled care and long-term care. It is important to understand the difference between the two because skilled care is covered by medical insurance and long-term care is not.

The term “skilled care” refers to services provided by health care professionals such as physicians, nurses, physical, occupational and speech therapists, medical social workers and others. These services can be provided in a hospital, a nursing home, an out-patient setting or at home.

Jill is in a nursing home for rehabilitation after knee replacement surgery. She is receiving physical therapy. Ellen has returned home after back surgery. A home health care nurse as well as a physical and occupational therapist visit her while she completes her rehab. Both Jill and Ellen are receiving skilled care that medical insurance covers.

  • Skilled care must be ordered by a physician.
  • The services that are provided are based on an assessment that establishes goals for improvement and/or maintenance of function. Typically we think of skilled care as the nursing care and therapy a patient receives during rehabilitation following a surgery, injury or other health event.
  • Skilled care ends once the goals are met and no further improvement is anticipated.

One thing that I think creates confusion for people is that some tasks we associate with long-term care services are paid for by medical insurance because they are part of the doctor’s order for skilled care. For example, the doctor’s order for home health might call for a periodic visit from a nursing aide—a caregiver–to assist with bathing, in addition to nursing visits and therapy. This leads some to think that medical insurance covers the services of a caregiver generally and that is not the case. The non-skilled bath visit it is covered by medical insurance because it is part of the order for skilled care, is short term and intermittent. The 3 critical components here are ‘doctor’s order’, ‘short term’ and ‘intermittent’.

The term “long-term care” refers on-going personal care provided by para-professionals, such as certified nursing assistants, home health aides, homemakers, or family members. Long-term care is sometimes called custodial care.

Mary was admitted to a nursing home for rehabilitation following hospitalization and surgery for a broken hip. She received physical and occupational therapy. While Mary was in rehab receiving skilled care Medicare paid for all the assistance she needed. Mary reached a point where she was no longer improving. Unfortunately, she was not doing well enough go home. She still needed assistance with bathing, dressing and managing her medications. Mary is not able to go up and down stairs safely. She is not strong enough to do housework, grocery shopping and other tasks that she would have to do to live at home. Mary has used up her Medicare covered days for skilled care and is now a long term care resident at the nursing home. She is responsible for paying the nursing home.

Georgia had a stroke and is no longer able to care for herself. She lives in her own home and employs private caregivers to care for her. Georgette has long-term care insurance which pays for the cost of her caregivers. Both she and Mary are long-term care recipients

  • Long-term care does not require a physician’s order.
  • The goal of long-term care is to help an individual do what they can no longer do for themselves and to maintain quality of life. The type of care provided is assistance with personal care—the activities of daily living such as bathing, dressing, grooming, walking, eating and toileting as well as with tasks such as fixing meals, grocery shopping, errands and housework.
  • Long- term care is ongoing—and long term.

Payment for long-term care is the responsibility of the individual. Medicare and medical insurance do not pay for long-term care. Long-term care insurance is designed to pay for long-term care. Eligibility for benefits, the waiting time required before payment begins, the payment amount and length of time of coverage vary according to the particular policy.

Medicaid is the primary payer of long term care in nursing homes for low income aged and/or disabled individuals who have exhausted their personal resources and meet the income eligibility requirements. Medicaid also pays for a limited amount of home and community services for low income individuals. Some employer medical insurance contains a long-term care benefit. If you are a veteran you may be eligible for benefits and/or pension funds that can be used to cover long term care costs.

I hope this post makes clear to you the difference between these two types of care because I strongly believe that if you are an educated consumer you will be able to navigate the health care system more successfully.

Comments

  1. I never knew about the differences between skilled and long-term care. My grandfather had a stroke, and I imagine that he had skilled care for a time. Now my grandmother takes care of him, eliminating the need for long-term care. Thank you for the help, I’m sure I’ll be able to navigate the health care system more successfully.

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