Below is a list of commonly accepted payer sources in long-term care facilities along with a brief description of each.
PRIVATE FUNDS – Money paid directly by individuals.
MEDICAID – Medicaid is a federally subsidized State program that may cover, in part or in whole, the cost of a semi-private room, meals, and general nursing care in a Medicaid certified long-term care facility. Encore Healthcare and Rehabilitation is Medicaid certified, so we are able to provide guidance throughout the Medicaid application process. In order for the State to determine if one qualifies for Medicaid assistance, it will do a detailed analysis over the past several years of money and assets the applicant held, owned, sold, gifted, and/or transferred ownership. It will also look at one’s current reoccurring income. Most states will carefully scrutinize financial records and transactions over the past 5 years; however, they can look back as long as they feel necessary. In general, States will allow Medicaid recipients to have one home and one car of reasonable value, a burial plot, a prepaid funeral plan, and a minimal amount of cash or savings. If an applicant is approved for Medicaid benefits, the State will determine, based on the applicant’s reoccurring income, the amount owed to the long-term care facility each month by the individual. Medicaid will then cover the remaining charges owed to the facility.
MEDICARE – Medicare covers semi-private rooms, meals, skilled nursing and rehabilitation services, and other medically-necessary services and supplies for up to 100 days in a long-term care facility. These benefits only begin following a 3-day minimum medically-necessary inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day one is formally admitted into the hospital with a doctor’s order but does not include the day of discharge. To qualify for care in a skilled nursing facility, one’s doctor must clarify that daily skilled care like physical therapy or intravenous injections are needed. The maximum days Medicare will cover in a skilled nursing facility is 100, although, the facility may be required to discontinue Medicare benefits prior to day 100 if at any point one’s condition ceases to improve, or if one meets predetermined goals set by the facility. Of those 100 days, Medicare will cover 100% of the charges for the first 20; however, a co-payment is required for days 21 through 100. Medicare does not cover long-term care or custodial care, so if one decides to remain in a long-term care facility after Medicare benefits are discontinued or exhausted, other methods of payment will be required.
THIRD PARTY INSURANCE – Insurance companies may cover, in part or in whole, a stay in a nursing facility depending on the type of insurance policy carried by an individual. Medicare replacement and managed care policies may cover a short-term stay for skilled nursing care and/or rehabilitation services. Long-term care policies may cover a long-term stay in a facility when skilled nursing or rehabilitation services are not required. Depending on the specific terms of each policy, it is important to understand that deductibles, copayments, and non-covered charges may be owed to the nursing facility by the policy holder. It is strongly recommended one completely understands the terms and conditions of their insurance policy before admitting into any nursing facility.