2. Pay with Your Own Funds?
This is the method many people are required to use at first. Quite simply,
it means paying for the cost of a nursing home out of your own pocket.
Unfortunately, with nursing home bills exceeding over $72,000 per year in
our area, few people can afford a long term stay in a nursing home.
3. Medicare - This is the
national health insurance program for people 65 years of age and older,
certain younger disabled people, and people with kidney failure. Medicare
provides only short term assistance with nursing home costs and only if
you meet the strict medical qualification rules.
4. Medical Assistance -
Also known as "Medicaid," this is a federal and state funded medical benefit program.
It is administered locally and by the state and can pay for
the cost of the nursing home if certain asset and income tests are met.
Since the first two methods are
self explanatory, our discussion will concentrate on Medicaid and
Medicare.
What About
Medicare?
There is a great
deal of confusion about Medicare and Medicaid.
Medicare is the
federally funded and administered health insurance program primarily
designed for older individuals (i.e., those over age 65). There are some
limited long term care benefits that can be available under Medicare. In
general, if you are enrolled in the traditional Medicare plan, and you've
had a hospital stay of at least three days, and then you are admitted to a
skilled nursing facility (often for rehabilitation or skilled nursing
care), Medicare may pay for a while. If you are a Medicare Managed Care
Plan beneficiary, the three day qualifying hospital stay may not be
required to qualify.
If you qualify,
traditional Medicare may pay the full cost of the nursing home stay for
the first 20 days and can continue to pay the cost of the nursing home
stay for the next 80 days, but with a co-pay that's over $100 per day.
Some Medicare supplement insurance policies will pay the cost of that
deductible. For most Medicare Managed Care Plan enrollees, there is no co-pay
for days 21 through 100, as long as the strict qualifying rules continue
to be met. So, in the best case scenario, the Traditional Medicare or the
Medicare Managed Care Plan may pay up to 100 days for each spell of
illness. In order to qualify for this 100 days of coverage, however, the
nursing home resident must be receiving daily "skilled care" and
generally must continue to "improve." (Note: Once the Medicare
and Managed Care beneficiary has not received a Medicare covered level of
care for 60 consecutive days, the beneficiary may again be eligible for
the 100 days of skilled nursing coverage for the next spell of illness.)
While it's never
possible to predict at the outset how long Medicare will cover the
rehabilitation, from our experience it usually falls far short of the 100
day maximum. Even if Medicare does cover the 100 day period, what then?
What happens after the 100 days of coverage have been used?
At that point,
you're back to one of the other alternatives...long term care insurance,
paying the bills with your own assets, or qualifying for Medical
Assistance.
What is Medical
Assistance?
Medicaid is funded
by both federal and state funds and is administered by the state. The
program will pay for the cost of the nursing home if the resident meets
certain asset and income tests. Medicaid program rules differ from state
to state. The Pennsylvania version of the Medicaid program is called
"Medical Assistance."
One of the primary
benefits of Medical Assistance is that, unlike Medicare which pays for
only skilled nursing, the Medical Assistance program will pay for long
term custodial nursing home care.
To qualify for
Medical Assistance in Pennsylvania, a person entering a nursing home must: (1) Be at least
65 years of age, blind, or disabled; (2) Be a resident of Pennsylvania;
(3) Need the level of care provided in the nursing home; (4) Meet the
financial qualification rules; and (5) Not be ineligible due to a recent
transfer of assets.
An applicant for
Medical Assistance must qualify both financially and medically. The
financial qualification rules are discussed below. To qualify medically,
your doctor must certify that you need the level of care being provided by
a nursing facility. In addition to that, the local Office of Aging is
required to complete an assessment (known as the Options assessment) to
determine if you require this level of care. In order to be eligible for
Medical Assistance benefits for nursing home care, the Office of Aging
must decide that nursing home level care is essential and that you could
not adequately be cared for in another setting.
Why Plan for
Medical Assistance?
As life expectancies
and long term care costs continue to rise, the challenge quickly becomes
how to pay for these services. Few people can afford to pay $6000 or more
each month for the cost of nursing home care, and most of those who can
pay find that their life savings have been depleted in a short time.
Fortunately, the Medical Assistance program is there to help.
Unfortunately, a person seeking Medical Assistance for help in paying
nursing home costs must qualify under complicated income and asset rules.
Please note: the Medical Assistance rules are very complicated, confusing
and vary from state to state (interpretations within a state can also
vary). Please seek help from a knowledgeable professional!
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Marshall & Associates www.paelderlaw.com
