| Financial
INFO
Who Pays For Care?
Much has been written recently concerning
health care costs and cut backs in government entitlement programs
such as Medicare and Medicaid. What does this mean for individuals
in search of a senior care facility?
Individuals are responsible for
paying for their own care to the extent that they have the means
to do so and are not covered by insurance. Paying with personal
funds is known as private pay. Private pay, insurance and the
various government programs are outlined below.
Private Pay
If an individual has assets, he or she
is expected to pay with personal funds until the money and assets
(other than those funds excluded by law) runs out. A spouse
has a legal obligation to pay for nursing home costs unless
the ill spouse qualifies for Medicaid. Children and other family
members (other than the spouse) are generally not required to
pay in most states, but they may choose to in some cases.
Some facilities only accept private
pay patients. If a facility elects not to participate in the
government reimbursement programs (Medicaid and Medicare), they
may only accept private pay patients. This is a business decision
made by management based on the economics of their facility.
For example, if a facility has many amenities that were expensive
to construct, and a state's Medicaid reimbursement policy does
not allow for adequate cost recovery (i.e., their reimbursement
rates are too low), a facility may be forced to only accept
private pay patients to meet their budgets.
Medicare: Does it Cover the Cost of
Nursing Home Care?
Medicare covers the cost of a nursing home
stay only under certain circumstances. The criteria are as follows:
1. The individual requires skilled
care (i.e., nursing care other than general custodial, intermediate
or personal care).
2. The care is provided only after
a three (or more) day hospital stay for treatment of the same
illness or condition that was treated in the hospital.
3. The nursing home is a Medicare-approved
skilled nursing facility with a registered nurse on duty 24-hours
a day.
4. The patient is assigned to a
bed that is Medicare-certified for reimbursement.
5. Only a nursing home can provide
the skilled care required.
Even if these criteria are met,
Medicare only covers the costs of care for up to 20 days. An
additional 80 days may be provided on a co-payment basis.
For more information on Medicare
benefits, visit the Medicare web site.
Medicaid: Who is Eligible?
Medicaid regulations allow nursing home
care to be provided for the poor or those that become poor.
Different states have different rules that define "do not
have the means." Divesting assets in order to qualify for
Medicaid has been a continuing problem for state administrators
resulting in regulations that limit the period in which an individual
may divest assets prior to entering a care facility. Rules for
Medicaid eligibility vary between states. However, the primary
qualifications for Medicaid to provide for long-term care in
a nursing home include the following:
1. Be at least sixty-five, blind
or disabled as determined by the state;
2. Be a resident of the state which
would provide the Medicaid benefits;
3. Need the type of care provided
by a nursing home;
4. Meet the income limitation test;
and
5. Meet the assets limitation test.
You may learn more about Medicaid
benefits in your state by contacting your state's Department
of Health and Social Services.
|