Monday, January 12, 2015

How to Pay for Nursing Home Care

Medicare Part A
  • Covers up to 100 days of skilled care at a Medicare certified nursing home
  • Must have a three day hospital stay within the 30 days prior to admission (observation stay and emergency room visits do not count)
  • Must meet skilled care requirements – therapy of 150 or more minutes per week, stage 3 or greater wound, IV antibiotics, etc. 
  • Medicare pays in full for the first 20 days, then there is a coinsurance due of $157.50 per day for days 21-100 of the stay which can be covered under a supplemental policy if coverage is in place, but would be due privately otherwise
  • Some days may be used while in the hospital prior to admission if cared for in their skilled or transitional care unit so you may not have 100 days available when you arrive at the nursing home

Medicare HMO or commercial insurance plans
  • Each plan has its own rules on coverage eligibility, coinsurance amounts, maximum number of days, and which nursing homes you can go to for care

Veterans Administration
  • May cover services but is based on VA rules and individual needs
  • Must go to a VA home or one that is contracted with the VA to provide services

Long term care policy
  • Policies differ greatly and must be looked into on an individual basis – some pay only after Medicare stops or only for a certain number of days or only if at a skilled level of care and daily rate can be as low as $25 
  • Patient or family must generally complete claim forms and get required documents from the nursing home to make an initial claim and usually have a short time limit to do so

Private resources
  • Savings, income, retirement plans, reverse mortgages, etc.

Medical Assistance
  • Payer of last resort
  • Must reduce assets to below government limits and pay your income to the nursing home as your portion of the cost of care (allowed a small personal allowance each month for clothing, newspapers, TV, etc. of $45 currently)
  • Cannot give away or sell property at below the fair market value or you will be penalized and can risk losing coverage for months or even years and would be responsible privately for nursing home care for that time period
  • If you are deemed to be a short-term patient, may qualify for a home maintenance deduction, which allows you to keep part of your monthly income to maintain your home (mortgage, taxes, utilities, insurance, etc.) to a maximum of six months
  • Special rules apply for patients who have spouses in the community or blind/disabled/minor children
  • Must meet the qualifications as a “skilled nursing” level resident through the Area Agency on Aging’s “OPTION” process – the agency will review the case and make the assessment on whether a patient is personal care, skilled nursing, or other level of care eligible

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