Paying for Care

Paying for Care and Services

Payment options for short-term/post-acute/skilled care are different than payment options for long-term care services. The options and programs that cover these services are quite complex and regularly subject to change. The information provided below is general information that can help explain basic differences but you are urged to speak with a social worker or admissions coordinator at any of our nursing centers for more detailed and specific information.

NOTE: The terms “skilled nursing center” as used below is interchangeable with “nursing home” when the nursing home is Medicare certified, which applies to most nursing homes.

Reimbursement Sources

Payor Sources For Long-Term Care

  1. Medicare: A Federal government program providing coverage for individuals who are over age 65 or who are permanently disabled. Medicare coverage and definitions are very complex and the information here is only intended to provide an overview of services covered. Specific detailed information should be confirmed through the Medicare web site or your health care provider. Medicare does not pay for any long-term “custodial” type care in any setting.

    Medicare coverage is broken out in several parts that include:

    Part A: This pays for inpatient care in hospitals and for short-term skilled nursing services in nursing homes. Part A also covers skilled home care and hospice care. Medicare pays for skilled care in a nursing home for up to 100 days after a 3-day qualifying stay in an acute care hospital. It does not pay for any long-term or custodial care.

    Part B: Medicare Part B pays for doctors office visits, diagnostic tests, durable medical equipment, certain mental health services and outpatient therapeutic services such as physical and occupational therapy. In Long Term Care settings Part B can pay for physical and occupational therapy when needed even if a resident has not been hospitalized.

    Part C: Medicare Part C is not really a separate coverage area. It is the terminology used to refer to the Medicare policy that allows recipients to select Medicare Advantage Plans where private insurance provides at least the services included in “Original” Medicare benefits but may also include additional services. Individuals with Medicare Advantage Plans can receive skilled nursing home care as part of the benefits, but those benefits must be authorized by the specific insurance plan.

    Part D: Medicare Part D is the Medicare outpatient prescription drug benefit. This benefit can help pay for prescription drugs when a Medicare recipient is living in a long-term care setting such as nursing home or assisted living.

  2. Medicaid: Medicaid is a joint federal and state program that pays for the care of individuals who have exhausted their personal savings and financial assets and cannot pay for their own care. Because of the high cost of nursing home care, many individuals needing long-term nursing home care exhaust their personal savings, and as a result, qualify for Medicaid. Medicaid pays for more than one half of residents living long-term in nursing homes. The Federal government requires states to include long-term custodial nursing home care as a basic Medicaid benefit. The Federal government reimburses states approximately 50 percent of the cost of Medicaid-covered services. Medicaid payments to providers are set by each state within certain federal guidelines.
  3. Private Payment: This term refers to payment for services from an individual or families personal assets, savings or income.
  4. Commercial or Private Insurance: Insurance companies such as Anthem Blue Cross, Harvard Pilgrim or United/AARP may pay for either short-term skilled care in a nursing home setting utilized by individuals under age 65 or may pay for portions of care not covered by Medicare such as deductibles and co-payments. Commercial insurers also pay for coverage of skilled care for individuals who have opted out of original Medicare and are members of a commercial “Medicare Advantage” plan.
  5. Long-Term Care Insurance: There are a number of private commercial insurance companies that offer specific insurance policies to cover long-term care services. These plans are designed to help pay for long term nursing home or assisted living care and some also pay for home care. LTC insurance plans usually pay only a specified amount per day for care and the duration of the insurance covered is usually specified as 1, 2 or 3 years.
  6. Veterans Benefits: Qualified veterans may be eligible to receive certain long-term care benefits either directly from the Veterans Administration or receive coverage to help pay for services provided by private providers. Specific information should be sought from the Veterans Administration.

Paying For Short-Term Skilled Care

Medicare Part A can cover up to 100 days of skilled nursing care in a licensed skilled nursing center, providing you had a qualifying 3-day inpatient hospital stay and the skilled services you receive in the nursing home are related to that hospitalization. Skilled nursing services include rehabilitative services under the definition.

Please Note the Following:

  1. The length of Part A coverage is determined by the provider, and the services must be certified by the attending physician. It is also important to note that the 3-day inpatient qualifying hospital stay does not include time in the hospital that the hospital classifies as an observation stay. This is a critical issue, as many patients may receive care in a hospital emergency department and are transferred to an inpatient medical floor and part or all of that care may be classified as observation stay NOT inpatient stay.
  2. If you qualify for Part A, then Medicare will pay all costs for the skilled nursing home stay for the first 20 days. Beginning on day 21 of a skilled stay, you will be responsible for a co-payment for the remainder of your stay (up to 100 days).
  3. If your stay extends to 21 or more days and a co-payment is necessary, many commercial insurance Medicare Supplemental policies (“Medigap” policies) will cover some or all of the co-payment charges. If a patient does not have such co-payment coverage but they qualify for Medicaid, then Medicaid may pay for the co-payment. If an individual does not have insurance or Medicaid coverage for the co-payment, they will be directly responsible for the co-payment. As of January 1, 2016 the co-payment rate is $161.00/day and changes each January.

Medicare Advantage Plan Coverage

Individuals who have selected a Medicare Advantage Plan in place of traditional Medicare coverage will have similar coverage as described above.

Commercial or Employer Sponsored Insurance Coverage

Commercial insurance plans vary widely in what services they cover. Many plans do provide some coverage for short-term /post-acute care in a skilled nursing center and you should verify coverage with your insurance plan.