Medicare will not pay for it. Medicaid will, once there is nothing left.

A household that has done everything right can still meet one bill it never insured. Not a hospital bill, which Medicare handles. The bill for someone being helped through an ordinary day, every day, for years.

That care is excluded from Medicare by name in federal law. Private health insurance does not cover it either. What is left is a short list: pay for it from savings, hold a long-term care insurance policy bought years earlier, be cared for unpaid by family, or qualify for Medicaid.

Medicaid is where most long stays eventually land, and it is worth being precise about what that means. Medicaid is a joint federal and state program for people with limited income and resources. The federal government sets an outer frame and each state builds its own program inside it, so eligibility figures, the treatment of particular assets and the aggressiveness of recovery afterwards all differ by state. Two families in identical circumstances on opposite sides of a state line get different answers.

This guide is educational information. It is not legal, tax or financial advice.

Medicaid pays for nursing facility care. It also pays, in every state to some degree, for care delivered at home under what are usually called home and community based services. Getting to either means satisfying two separate tests.

The income test asks what arrives each month. Pensions, Social Security and withdrawals all count. Many states cap countable income at a figure tied to the federal benefit rate, and states that do usually allow an income trust as the route through for someone over the line. Almost all of the income then goes to the facility each month anyway, leaving a personal needs allowance. Federal law sets only a floor for that allowance and each state sets its own, so what a resident keeps for everything that is not care varies considerably.

The resource test asks what is owned. The countable limit for a single applicant is low, in most states a few thousand dollars. Some things are not counted at all, and the usual list includes the home while the applicant or a spouse lives in it, one vehicle, personal effects and household goods, and prepaid burial arrangements. Everything else is countable and has to be spent before Medicaid pays anything.

The phrase for that process is spending down, and it is exactly what it sounds like. The money goes to the nursing home at private rates until it is gone, and only then does the program begin.