Month: April 2023

According to the Centers for Disease Control and Prevention (CDC), there are more than 15,000 skilled nursing communities (or nursing homes) nationwide. The search for proper care for a loved one or yourself is a complicated process, especially regarding payment. Your skilled nursing stay may be covered if you are eligible for Medicare. Find out how Medicare can pay for a stay at a skilled nursing facility.

What is skilled nursing care?

Skilled nursing facility care takes place outside of the home in a Medicare-certified community that provides medical (or skilled) services to individuals in need.

According to UnitedHealthcare, “Patients may go from the hospital to a skilled nursing facility to continue recovering after an illness, injury or surgery.” Skilled nursing communities can serve as long-term care residences or short-term, transitional care solutions to help someone recover from a medical event.

Residents are mostly older adults living with chronic conditions who need medical supervision and care management. Approximately 1.3 million residents live in nursing homes (as of 2017), approximately 0.5% of the population. 

Does Medicare pay for a stay in a skilled nursing facility?

Medicare does pay for certain parts of a skilled nursing facility stay. There are specific circumstances and sequences of events that have to be considered first. 

Here are some of Medicare’s qualifying criteria to cover a short-term stay in a skilled nursing facility:

• •You have Medicare Part A and have hospital insurance days remaining in your benefit period.
• •You have a “qualifying inpatient hospital stay.”
• •Your doctor has certified that you need skilled nursing care.
• •You searched for and want to be admitted into a Medicare-certified community.
• •Your condition is related to your hospital stay or occurred while you were in the hospital.

What is a qualified inpatient hospital stay?

Medicare covers skilled nursing care after a qualifying inpatient hospital stay. This means that, throughout your stay, doctors have determined a medical necessity for skilled nursing care after you are discharged. Staying in the hospital “under observation” only typically does not qualify. 

The hospital stay must include more than three inpatient days, as stated in the Two-Midnight Rule, for Medicare Part A to cover a subsequent stay in a skilled nursing facility.

There are constraints to skilled nursing facility coverage from Medicare. Skilled nursing stays will not be covered if you only need “custodial care.” This is a type of care that unlicensed professionals can provide. 

In addition, your skilled nursing facility admission has to occur within 30 days of your discharge from the hospital for a reason related to your inpatient hospital stay. For example, if you were admitted into the hospital for congestive heart failure but want to be admitted into skilled nursing care for an untreated back injury (that did not occur at the hospital), this would not count. 

What timeframe does Medicare cover skilled nursing care? 

Medicare has certain guidelines regarding the timing and length of stay when determining whether it will cover skilled nursing care.

• •For days 1-20 at the skilled nursing facility, the patient incurs no costs associated with this care.
• •For days 21-100, the patient pays a daily 20% coinsurance. This means that Medicare pays 80% of the daily costs, and you are responsible for the other 20%.
• •There is a 100-day limit on skilled nursing facility coverage per benefit period. Your benefit period begins the day that you are admitted to the skilled nursing facility. This means that on the 101st day, you are responsible for paying 100% of the daily costs.

What services within an SNF might Medicare pay for?

Medicare pays for medically necessary services, which means that it would only be paying for: 

• •Shared rooms (you would likely not be the only person staying in the room).
• •Meals.
• •Medical care provided by a licensed vocational nurse, licensed practical nurse, registered nurse, nurse practitioner, or physician.
• •Therapies pertinent to your care (if you are admitted for a leg injury, speech therapy, for example, would not be covered).
• •Relevant social services.
• •Prescriptions and medications that will help you achieve your health goals.
• •Supplies and durable medical equipment.
• •Emergency transportation (if other modes of transportation would hinder one’s health).

What to do if you’re looking for skilled nursing care

You might be looking for a skilled nursing facility while you or your loved one is still in the hospital. Don’t wait to start your search if they’re in the hospital now. You may only have one or two days’ notice of the hospital’s plan to discharge the patient, and it’s important to find the right facility that meets your or your loved one’s needs.

If you’re in the hospital

If you want to know if Medicare will cover your skilled nursing care, keep in close contact with discharge planners, such as your case manager or social worker, from the time you’re admitted to the hospital and one is assigned to you.

The hospital case managers and social workers likely have lists of facilities in the area. You should also research to find a facility near you and to ensure that the facility you choose offers the services you need and has good reviews. 

When contacting potential skilled nursing facilities for your stay, confirm they are certified to provide Medicare-covered care. They’ll be able to provide you with clear financial details on paper. 

If you’re at home (or in a senior living community)

Contact your doctor to confirm your medical need for this type of care. When evaluating providers of skilled nursing care, contact the facility’s admissions director to confirm that it is a Medicare-certified provider. 

You can also look at ProPublica, which has published over 80,000 inspection reports that detail facility fines, violations, and more. 

Conclusion

The search for skilled nursing is complex, but knowing that Medicare covers some of its services can bring peace of mind. Several other ways to pay for skilled nursing care include long-term care insurance, Aid and Attendance for Veterans, and more. 

The search for assisted living can be a stressful journey when you’re navigating uncharted territory. It doesn’t have to be. If you are one of the 13.2 million people who receive Medicare, it’s helpful to know your options for using it to help pay for long-term care expenses. In this article, we’ll go over what Medicare is, what assisted living is, how Medicare may help cover assisted living-related expenses, and what the next steps might look like. 

What is Medicare? 

Medicare is a federal health insurance program designed for individuals 65 and older, paid through Social Security employee taxes. Certain individuals living with disabilities and other qualifying conditions may also be eligible to receive Medicare even if they are under 65. Medicare is different from Medicaid, though; the two insurance programs are commonly confused. Both can help cover health-related costs, but knowing the differences and understanding the details of Medicare vs. Medicaid is important. 

In 2021, Medicare spending accounted for 10% of the federal budget, according to health policy research organization KFF. This amounted to $829 billion. Medicare covers a few different categories of costs, such as hospital, health, and prescription drug costs. 

The four parts of Medicare (Parts A, B, C, and D) each cover a different category of these products and services. Long-term care spending, which would apply to assisted living, belongs to Medicare Parts A and B. 

What is assisted living?

Assisted living is a form of residential care designed for older adults who need some but not total support with their day-to-day activities. 

Assisted living generally includes a private or shared room, daily meals, a monthly calendar of activities, and private areas for study and leisure. Assisted living is a beneficial residential setting when living at home may no longer be safe or when an older person who needs some daily support wants to live closer to family without moving into the family home.

Does Medicare pay for assisted living?

Medicare doesn’t pay for rent at assisted living because this type of support is nonmedical or not “medically necessary” in nature. The main supports and services assisted living communities offer are nonmedical and might include housekeeping, laundry, socialization, and assistance with activities of daily living, like bathing, dressing, eating, transferring to and from bed, and ambulating. Medicare defines medically necessary services as those that “diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine,” so many typical assisted living services don’t qualify.

Medicare’s core offerings are: 

• •Part A is hospital insurance: This is focused on inpatient care.
• •Part B is medical insurance: This is focused on outpatient care.
• •Optional Part C is Medigap/Medicare Advantage: This is supplemental, private coverage a person can choose to have instead of original Medicare.
• •Optional Part D: This is prescription drug coverage.

What services within assisted living might Medicare pay for?

Though Medicare doesn’t cover assisted living, it does cover durable medical equipment, which could include a wheelchair, oxygen equipment, and other supplies that you need to manage your health. 

Medicare also covers preventative care services, encouraging members to manage their health proactively. Examples include flu shots, diabetes screenings, mammograms, and more. 

Original Medicare covers home health care intermittently or long-term as long as you demonstrate a need for skilled or medical services and are “bedbound.” Examples include wound dressing and physical therapy. 

Medicare-covered home health care services are at no cost to you; however, once you meet your Part B deductible, you are responsible for paying 20% of the Medicare-approved amount for that service or device. Here’s some information that breaks down approximate costs and what you may be responsible for. 

If you work with a home health care company, they should give you notice ahead of time, explaining what Medicare will cover and what you’ll be responsible for. 

Medicare Advantage (Medicare Part C)

Medicare Advantage plans, also known as Medicare Part C, don’t cover assisted living; however, they are more flexible with covering additional services as part of their benefit design. What’s more, for every person eligible for Medicare, there are roughly 39 options for them to choose from. Many of them come with a $0 monthly premium. 

Certain assisted living and other senior living communities also have their own Medicare Advantage plans for residents. Here is one example from Erickson Senior Living. 

Some plans within Medicare Advantage (MA) have a Part B giveback program. They may also cover in-home care services, adult day care, meal delivery, and other services related to assisted living. They develop provider networks for services that members need, and you can choose from a list of providers in your area based on your needs. 

For services that MA plans don’t cover or offer, they may be able to refer you to a service provider or a company that can point you in the right direction. 

Conclusion

Medicare does not pay for assisted living, but it does help with many of the costs of other health-related services and products older adults use. It can assist with coverage for certain inpatient hospital stays, hospice care, durable medical equipment (DME), and preventative care services. 

If assisted living costs are an issue, there are other ways that you can pay for assisted living. Aside from private or self-pay, you can look into a reverse mortgage, long-term care insurance, or the Aid and Attendance benefit if you’re a Veteran. If you’re dually eligible for Medicaid and Medicare, you may be able to utilize Medicaid to help pay for some other costs.

Medicare Advantage may be an attractive alternative to help people with specific needs, including Veterans, people living with diabetes, and segments of the population covered under D-SNPs, or special needs plans. Private companies offer Medicare Advantage plans and have many rules about the services and products they cover and how much they will cover. If you’re considering a Medicare Advantage plan, be sure to do your research to understand the plan you’re purchasing.

Figuring out how to pay for long-term care is important in finding the right senior living option to suit your or your loved one’s needs. Because costs for long-term care can add up quickly, you may weigh the costs, benefits, and drawbacks of moving to an assisted living community instead of continuing to live at home. If you or your loved one has Medicaid insurance or you think you might qualify, you might wonder what senior care Medicaid covers. When it comes to paying for assisted living, Medicaid may be able to help in some circumstances. Here, we explain how Medicaid intersects with long-term care and how it may help cover assisted living costs in some states.

Medicaid and long-term care

Medicaid is an income-based state and federal public health insurance program in the United States. Currently, 7.2 million older adults receive support through dual eligibility, which means they are eligible to receive Medicaid and Medicare at the same time. 

Medicaid is also the nation’s primary payer source for long-term care costs. Medicaid has income-limit eligibility requirements and serves a variety of population groups, including children, pregnant women, low-income adults, people living with disabilities, and seniors. This program is different from Medicare, a health insurance program that typically insures adults age 65 and over, regardless of their income. For older adults, Medicaid covers certain costs that Medicare doesn’t cover. Learn more about Medicaid vs. Medicare here.

According to KFF, Medicaid covered $53 billion in institutional care costs and $162 billion in home and community-based care services. 

What is assisted living? 

Assisted living is a residential option for older adults when they need moderate support with their activities of daily living (ADLs). This includes:

• •Bathing.
• •Eating.
• •Dressing.
• •Toileting.
• •Continence.
• •Transfers.

Assisted living is an alternative to living at home that allows residents to downsize while receiving the appropriate care they need. Facilities provide meals and activities as well as support with personal care services. 

According to Haven Senior Investments, approximately 30,000 assisted living communities are operating in the U.S. They also found that over 800,000 residents occupy these communities. 

Does Medicaid pay for assisted living?

Medicaid rules and regulations are determined on a state-by-state basis. Therefore, it’s essential to understand what your specific state covers and what eligibility requirements they have in place. 

In some states, Medicaid does cover assisted living, while others don’t. Even if a state allows assisted living communities to accept Medicaid, not all communities in that state will or may not have proper certification. 

For example, in California, Medi-Cal, the state’s Medicaid program, can cover some assisted living costs. Residents who meet the location, financial, and medical criteria can get their care covered via the Assisted Living Waiver (ALW) program. 

Contrastingly, Kansas, for example, does not cover assisted living costs through KanCare, the state’s Medicaid program. 

When searching for assisted living communities in your area, ask each one if they accept Medicaid as a payment method. You may use a Medicaid waiver to help pay for the community costs.

How do Medicaid waivers work to help pay for assisted living? 

Medicaid waivers function to waive certain eligibility requirements to a population who might otherwise not receive the care they need. States use their own discretion to design waiver programs that meet the needs of their population. 

There are two primary categories of waiver programs: freedom of choice section 1915(b) and home and community-based services 1915(c) waivers. Specific program names in your state may vary. You can check for waivers by your state on the Medicaid.gov website here. 

Some of the waivers may be called:

• •Frail Elderly (FE) Waiver.
• •HCBS (Home and Community-Based Services) Waiver.

Assisted living communities participating in the waiver program would be “HCBS certified,” so ensure that the communities you look at are properly credentialed. 

What are the basic rules to qualify for Medicaid?

Medicaid is an income-based program. There are a few eligibility requirements to receive benefits, with eligibility varying by state. You can see the rules in your state here. A few of the basic eligibility criteria are: 

• •Meeting your state’s Median Adjusted Gross Income (MAGI) benchmark.
• •Being an American citizen or eligible noncitizen (e.g., lawful permanent resident).

States may create “medically needy” programs for individuals with complex care needs. This helps families who may incur care costs that exceed their threshold to pay but don’t meet financial eligibility criteria for Medicaid. 

Conclusion

If you are searching for assisted living options in your area, your state’s Medicaid program may cover some of the costs. Make sure that you check waiver eligibility and other state-specific criteria beforehand. 

Fortunately, states like Pennsylvania are advocating for assisted living costs to be covered through Medicaid. Even if your state doesn’t cover these costs today, check back in the future.