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Health Care Benefits in Skilled Nursing Facilities

 

The Ins and Outs of Coverage Provided for the Resident

Is the time approaching when you or a loved will need to enter a nursing facility?

How will you pay for it? The options are confusing and can be overwhelming.

You are not alone. Thousands of people enter nursing care facilities every month with the same concerns. It is therefore important for a future resident and his/her family to fully understand their options.

A resident entering a skilled nursing facility to receive skilled services, including rehab, will generally be covered either under Medicare Part A or under a private insurance plan.

 

  • Medicare Part A

Medicare Part A covers residents in a Medicare-eligible facility for maximum 100 days, but coverage may be terminated earlier if the resident does not require skilled services or rehab anymore. These 100 days are referred to as a benefit period, and will be renewed if a resident does not require any skilled services for 60 consecutive days.

The first 20 days in the benefit period are covered by Medicare in full. Once the resident stays past the first 20 days, he/she is responsible for a co-pay of $164.50 daily for the remaining 80 days, which may be covered by a secondary insurance. This co-pay amount of $164.50 is increased yearly.

For the resident to be eligible for Medicare, the admission to the facility must be within 30 days of a qualifying 3-day hospital stay, or a stay in another facility covered under Medicare A.

To learn more about Medicare, please visit The Official U.S. Government Site for Medicare here.

 

  •  Private Insurance Plan

If a resident does not have Medicare, he/she will often have a private insurance plan to cover their skilled facility stay. This may be a commercial insurance (such as insurance received through an employer), a Medicare Advantage plan, or even a Managed Medicaid plan, depending on the state in which the resident resides.

Private insurance plans will only cover the resident for short term; the amount of days will depend on the specific plan and the resident’s benefit. Additionally, they will only cover while the resident medically requires skilled nursing care and/or rehab. The facility continuously sends updated medical records to the insurance plan who will then determine how long they will cover.

Depending on the resident’s benefit plan with the insurance company, there may be co-pays, co-insurances, and/or deductibles that will need to be paid out of pocket.

 

  • Veterans

Veterans can be eligible for financial assistance including VA benefits, Medicare, Medicaid, and other health insurance benefits. However, it is important to know that VA benefits can only be used at VA facilities and Medicare can only be used at facilities that are Medicare eligible. They cannot be used together, but Medicare or VA benefits can be used along with Medicaid and other health insurance benefits.

For more information regarding VA benefits, please visit The U.S. Department of Veteran Affairs website here.

 

Long Term Coverage in a Skilled Nursing Facility:

Once a resident is not covered under Medicare A or their private insurance plan, either because he/she used up the benefit or because he/she does not require skilled services, the resident may go home or become a long-term resident. Long-term care is also called custodial care and includes help with ADLs (Activities of Daily Living), such as bathing,dressing, using the toilet, eating, etc.

For further information regarding long-term health, please visit The Official U.S. Government Site for Long-Term Care here.

A long-term resident will pay privately for the Room and Board charge, when a resident cannot afford to pay privately anymore, it is time to apply for Medicaid.

  • Medicaid

Medicaid is a federal program, governed by the states, designed to provide health care to U.S. citizens with low income/assets. Since it is governed by the states, the eligibility requirements for Medicaid vary from state to state, and one may not use Medicaid benefits granted by one state in a different state.

For more information regarding Medicaid and its benefits please visit The Official U.S. Government Site for Medicaid here.

 

To be eligible for Medicaid in skilled nursing facility (known as Institutional Medicaid), the resident’s assets need to be below a certain limit, depending on the state. The resident is also required to give their income to the facility, although they could keep part of it for their personal needs.

The process of applying for Medicaid is always difficult and creates unnecessary stress for the resident and the resident’s family. Luckily, Senior Planning Services makes your life much easier by providing this service and more. To learn more about Senior Planning Services and how they can help, please visit our website here or call 1-855-S-PLANNING (1-855-775-2664).

In Summary, when a resident of a nursing care facility or his/her loved ones know their options it helps avoid confusion, gives clarity in terms of what they pay for, and it is a key to saving time and money. If the resident is a veteran, he/she may want to research VA benefits as that may be the better choice.

 





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