June 24, 2016 | by The Polyclinic
financial planning caregiving

Many patients are surprised to learn that medical insurance often does not cover
aspects of long-term care. Learn more about what you can do to prepare for long-term care needs.

In our previous two articles of this Caregiving series, we addressed ways to identify when your loved one needs a caregiver, and the importance of preventing caregiver stress and burnout. Our final installment introduces some financial considerations for long-term care including commercial insurance, Medicare, Medicaid and VA benefits. For specific eligibility requirements, benefits or legal options, contact a licensed professional in good standing with their licensing body specializes in insurance, financial, legal and/or government entitlement programs.

Commercial Insurance: What it Covers and What it Doesn’t

Commercial insurance plans, those usually provided through an employer or purchased privately, can cover a percentage of medical and dental office visits, services, hospital stays, emergency room visits, prescriptions, laboratory studies, diagnostic imaging, etc.

Skilled rehabilitation, personal care, or home health benefits are often defined in the plan and dependent on medical necessity, not financial need. If you have commercial insurance, it is very important to contact your insurer for an explanation of benefits (EOB) for all medical or rehabilitation services. Most commercial insurance plans do not cover long-term (90 days or more) skilled or personal care if you become disabled or unable to care for yourself.

Long-Term Care Insurance: What it Covers and What it Doesn’t

There are many companies in Washington state that offer private insurance policies that may help pay for long-term nursing home care, adult day care, assisted living, or in-home care. These private policies vary widely, and are often specific to certain types of care.

If you or your family member is already disabled or seriously ill, long-term care insurance may not be an option. If you already have a long-term care policy purchased years ago, review the benefits, limitations and medical documentation requirements. The Office of the Insurance Commissioner offers a wide range of information and assistance to consumers interested in learning more about long-term care insurance.

You may be eligible for long-term compensation or pension benefits through the Veterans Administration if you or a loved one has a disability or illness, is over 65 years old, permanently disabled and served on active duty in the military, and meet service and net worth requirements.

Medicare and Medicare Advantage Plans: What’s Covered and What’s Not

Medicare is a federally funded medical insurance program for people over age 65 or disabled adults. It covers a percentage (80%) of physician services, hospital stays, prescriptions, laboratory studies, imaging, home health and hospice care.

Medicare Advantage plans (also known as Medicare Part C) are a type of health plan offered by a private company that contracts with Medicare to provide Medicare benefits.

Many people believe that their Medicare or Medicare Advantage plan will pay for long-term skilled, custodial care, or memory care in a facility – they do not.

According to Medicare.gov, many people who require long-term nursing home care or memory care and are not eligible for Medicaid, will need to pay out of personal resources, such as savings or by selling assets. It’s possible for some people to reduce their financial resources and assets enough to qualify for Medicaid coverage.

If you or a family member are concerned about paying for long-term care and have questions about Medicaid eligibility guidelines, consult with an elder care attorney early, long before care is actually needed. The King County Bar Association offers a lawyer referral service to practicing attorneys in the greater Seattle, including elder law attorneys who specialize in this area.

Medicaid: What's Covered and What's Not

Medicaid is a state-funded insurance program for disabled individuals and older adults who qualify medically and financially.

It is important to keep in mind that not all facilities for long-term or memory care can accept Medicaid payment, and those that do may only have limited beds available. When considering a facility for long-term care, be sure to ask about their rules on Medicaid.

There are also special rules that apply to couples to prevent a healthy spouse from losing all their resources or assets to pay for their loved one’s care in a nursing or memory care facility. It’s possible for one spouse to become eligible for Medicaid assistance for nursing home residency while the other spouse resides at home with sufficient income to pay for both.

It is very important for older adults to review Medicaid guidelines with their family and/or consult with an attorney who specializes in elder law and/or Medicaid planning before making any decisions. The King County Bar Association provides Pro Bono Services, consultations and referrals through neighborhood legal clinics at several local senior centers and agencies to King County residents who cannot afford or access to an attorney.

The Take-Away: Be Prepared and Plan Ahead

Medical insurance pays for medical needs such as care by a doctor, tests, or procedures. Medical insurance does not pay for personal care needs such as housework, shopping, dressing and supervision in the home.

As life expectancy increases, planning for long-term needs is a critical factor influencing all aspects of life from living environment to level of care. Waiting too long to put a plan in place can result in unnecessary stress and complications for you and your family. Talk to your family and those close to you about outlining a plan and seek consultation from trusted medical, legal, financial and/or long-term care professionals to help guide your decisions.

Christine Winther, licensed clinical social worker in the Care Advantage Program, contributed to the content of this article.


  • Long-Term Care Guide - Download a free long-term care resource guide for more information and tips on planning.
  • Long-Term Goal Planning - If you or your family member is enrolled with a Medicare Advantage plan contracted with The Polyclinic, you have access to a social case manager who can review your long-term planning goals. Talk to your primary care provider for a referral for this service of the Care Advantage Program.