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Medicaid Myths in Long Term Care

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You may have heard a friend, family member or neighbor tell a story about an elderly relative that had “all their money taken by a nursing home” or “the state took all their money when they went into the nursing home”.  This is another one of those myths regarding coverage of long term care, like the one we covered in the last blog about Medicare.

Unlike Medicare, Medicaid does cover long term care, but you have to qualify. Medicaid both in the community and in a nursing facility is a program for low-income individuals who must qualify by meeting the income guidelines. When it comes to paying for nursing home care, you have to meet the medical criteria showing that you need the physical assistance, as well as, showing that you have no more than $4,000 is assets and no more than $2,000 in monthly income.

When someone states “the nursing home took all of my mother’s money”, most likely the Medicaid guidelines were not properly explained to them or it was oversimplified by the person explaining it. Often when someone is admitted to a nursing home for long term care, the nursing home must look at their financial records to see how they will pay for the care, they will counsel the person and /or their family on how much care at the facility costs and should help them determine if and when they will need to apply for Medicaid. When a person has enough money to pay, but knows they may run out in six months to a year, they call this a “spend down period” which means you pay the nursing home the monthly rate and when you’ve “spent down” your funds to the Medicaid eligibility level, you can apply for Medicaid.

There may be people who are under the false impression that Medicaid or some other program, will automatically cover you when you need nursing home care, similar to the false belief that Medicare covers long term care costs. We pay for goods and services all the time, but when it comes to long term care there is much confusion and false assumptions.

Medicare Myths

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According to a study done by Prudential in 2009 37% of people think that Medicare will cover their long-term care costs. This is false. Medicare does not pay for long-term care. Medicare is also not free, there is a monthly premium associated with Medicare Part B.

Here are the facts about Medicare.  Medicare is for people 65 years of age or older (or people with disabilities). Medicare Part A (also known as hospital insurance) covers hospital stays, short-term skilled nursing care, hospice and home care services. Medicare Part A does not have a premium (if you or your spouse have paid Medicare taxes).

Medicare Part B (also known as Medical Insurance) does have a premium that is paid monthly. Part B covers doctor’s services, outpatient care, home care services and some preventive services.

Back to long-term care, what Medicare does cover, under Part A is Skilled Nursing Facility care on a short term basis. There are several guidelines for that coverage that you should also be aware of. After a 3 day minimum hospital stay, you are eligible under Medicare Part A for a short-term stay in a Skilled Nursing Facility, for rehab and nursing services. The goal is to get the individual strong enough to return home.

What Medicare Part A covers is up to 100 days of this skilled care at a nursing facility. You may not need the entire 100 days. The staff at the nursing facility will estimate the amount of time needed to rehabilitate the patient based on Medicare guidelines for Physical, Occupational and Speech Therapies, as well as, medical interventions given by nursing staff. It is also important to note that there is a benefit period associated with your 100 days of Skilled Nursing Care. This means that if you use your 100 days, you will not be eligible for another 100 days (even if you have another 3 day hospital stay) for 60 days. During those 60 days you must not have received any Skilled Nursing services. So, keep this in mind when planning your discharge from the Skilled Nursing Facility. Another thing to keep in mind is that after 20 days in the Skilled Nursing Facility you are responsible for a 20% co-pay per day. The co-pay is based on the per day rate approved by Medicare. If you have a supplemental or Medi-Gap policy, this may cover your co-pay, call your insurance plan to verify this. It is very important when being admitted to a Skilled Nursing Facility to provide all of your insurance information, including you supplemental coverage.

In closing, Medicare covers many inpatient and outpatient services through Part A & Part B, but they do not cover long term care, also referred to at custodial care. It is important to know what Medicare covers when thinking of your short term and long term health needs.

For more information visit:

 www.medicare.gov Рto view the 2011 Medicare and You Handbook,

or call 1-800-633-4227 to request a Handbook.

http://www.medicare.gov/publications/pubs/pdf/10153.pdf – for a handbook on Medicare Coverage of Skilled Nursing Facilities