Paying for Long-Term Care & Exploring Payor Resources
Finding a skilled nursing facility (SNF) for care after an injury or illness for a loved one is a confusing and difficult time. Not only must one consider location, clinical services, activities, therapy teams and more, but also ensure the patient qualifies and meets all the requirements for the costs to be covered.
This blog is a basic overview of payment options. For more information or questions on your individual medical or financial situation, please contact a SNF you are considering for care options. A social worker can guide you through the process and help relieve some of the stress associated with the financial process.
Depending on your health care needs, specific situation and goals, there are multiple payor resources:
• Private Payment
• Traditional Medicare
• Medicare Advantage Plans
• Private insurance
Private payment is an option for those with significant resources. SNF care can be very expensive due to the levels of care required for patients. In many instances, private pay can be used as an option until the patient qualifies for other payor resources such as Medicaid.
Medicare is accepted for placement for those patients who qualify for the benefit and who meet the Medicare requirements for skilled services in a SNF. The qualifications briefly stated are:
• Patients who have had certain disabilities for more than two years
• Patients must have active Medicare Part A
• A three-night qualifying stay as an in-patient in an acute care hospital within the last 30 days prior to admission to a nursing facility
• Patients must require a daily “skilled service” while at the facility
The Medicare benefit covers the following:
• Pays 100% of the cost of medically necessary services during the first 20 days of placement. Services including room and meals, skilled care by licensed professionals, supplies and equipment, pharmacy services, physical, speech, occupational therapy, and nurse practitioners
• Beginning on day 21 and up to day 100, either the individual, Medicaid, or other supplemental insurance will be responsible for paying a coinsurance portion
Medicare Advantage Plans
Medicare Advantage Plans, sometimes referred to as an HMO or PPO, are offered by private companies approved by Medicare. Medicare pays these plans to cover your Medicare benefits.
Medicare Part A entitlement may cover costs for services listed above for up to 100 days. The individual must require a skilled service as defined by Medicare for the entire 100 days. There is no guarantee that 100 days can be used if the patient’s condition stabilizes.
The individual or responsible party must apply for Medicaid. As defined by the Medicaid program, eligibility is determined based on financial and medical need. This need is established by the applicant’s meeting four points of eligibility:
• Medical need
• Nursing home certification
• Monthly income
• Countable assets
Medical Need is established by the individual’s attending physician, who must certify the medical need and indicate that nursing home placement is needed.
Nursing Home Certification means the individual must be placed with a nursing home that is certified with Medicaid. Medicaid payment can only be made to those certified homes electing to participate in the Medicaid program.
Monthly income is reviewed by the local Medicaid office to determine eligibility of Medicaid benefits.
Countable Assets include but are not limited to money in checking/savings accounts, certificates of deposit (CDs), stocks, bonds, cash-on-hand, retirement accounts such as IRA’s, cash value on life insurance policies and property other than one’s home. The individual’s total countable assets cannot exceed $2,000 to be eligible for Medicaid.
Some private insurance companies offer a skilled nursing facility benefit. Prior to admission, and with your written permission, we will contact your insurer and ask about any skilled nursing facility benefits available through your policy.
Some private insurance plans are known as "Medigap" coverage. A Medigap policy is health insurance sold by private insurance companies to fill the "gaps" in Traditional Medicare coverage. Medigap policies help pay some of the health care costs that Traditional Medicare doesn't cover. If you have Traditional Medicare and have a Medigap policy, then Medicare and your Medigap policy will each pay its share of covered health care costs before you are billed for any covered charges.
As always, you should speak with the social services department of the SNF you are choosing for care. They can provide additional information on payor resources, forms, and answer questions about yours or a loved ones’ specific situation.
Author: Brandon S. Totten
Community Relations Manager, AMFM Nursing & Rehabilitation Centers