Placing a loved one in a nursing home can be a very stressful and confusing process. This article is intended to give you some basic facts about long term care.
Nursing homes are designed to enable caregivers to meet the needs of residents and to ensure their safety to the greatest extent possible. Fire alarm and sprinkler systems, wandering alert systems, emergency generators, fire walls and doors, smoke detectors, heat detectors, safety alarms on beds, chairs and exit doors are all intended to make residents as safe as possible while residing in the nursing facility.
Houses are seldom constructed to allow persons with disabilities to live safely therein. Obstacles like steps both inside and outside the home, bathrooms which cannot accommodate wheelchairs or walkers, narrow doorways, inaccessible laundry or cooking facilities and inappropriate flooring can make living at home difficult or impossible, particularly if there is no other person living in the home to assist with the activities of daily living.
Contrary to popular belief, Medicare does not pay for most nursing home care. You can find a wealth of information about Medicare on their website, www.medicare.gov. Think of Medicare like you think of your personal health insurance - it will pay when you meet the coverage criteria. Medicare pays for skilled care when there is a need for services that require a licensed health care professional to perform them. Medicare does not pay for “custodial care”, which includes services such as helping people eat, dress, bathe, use the toilet and walk, since these activities can be performed by unlicensed persons.
To qualify for Medicare coverage in a skilled nursing facility, a person must first have a three-day inpatient hospital stay. Upon being discharged from the hospital, the person must require skilled care in an inpatient setting such as intensive therapy or intravenous drug administration. Medicare will pay up to 100 days per “Benefit Period”. Medicare pays for all medical bills for the first twenty days of long term care. Beginning on the twenty-first day, the Medicare beneficiary must pay a copayment. This changes every year and can be found on the Medicare website; for 2008, the copayment amount is $128 per day. Most people have some form of Medicare supplement policy which pays some or all of this copayment amount. You should consult your individual policy to determine your coverage guidelines.
Medicare replacement policies have become very common, but these policies do not necessarily pay the same as Medicare does. While some pay exactly the same, others require policy holders to utilize specific facilities contracted with the insurance company that issued the Medicare replacement policy. Some pay fewer than 20 days at 100% and do not provide 100 days of coverage, so if you are considering buying a policy that replaces Medicare, be sure to compare all of the benefits carefully.
Inpatient care is paid for by Part A of Medicare. Medicare Part B pays for outpatient services, home health, durable medical equipment, physician office visits and therapy for nursing home residents who have not met the requirements for Part A coverage.
Medicaid is a program that pays for, among other services, long term care for persons who have spent all of their assets except for about $2000. If there is a spouse or disabled dependent who has been living with the Medicaid beneficiary, the limit is higher. The coverage criteria can be viewed at www.cms.hhs.gov/medicaideligibility/. Medicaid also has websites in each state. In Kentucky, my home state, the web address for Medicaid is http://chfs.ky.gov/dms/services.htm. Your local office should be listed in the blue pages of your phone book.
If you have more than $2,000 in assets, you must ”spend down” to qualify for Medicaid. Therefore, many people must pay for their nursing home care with their private funds. If you expect to deplete all of your funds, be sure to inquire about Medicaid eligibility before you spend all of your money because, in some states, you must be in a Medicaid certified bed in a nursing facility before you can apply for Medicaid.
Long term care insurance has become increasingly common. These policies pay varying amounts for varying time periods, depending upon the policy selected. Some policies only pay after Medicare benefits have exhausted. Consult your policy or insurance agent to see what your policy pays.
If you are contemplating nursing home placement, go visit the facility you are considering. You can tell a lot about a facility by just walking down the halls. The admissions staff can answer many of your questions, and tell you what their facility can and cannot do. For example, some facilities have specialized units for services such as rehabilitation, wound care, Alzheimer’s Disease, brain injuries or other specialties. Most facilities have a limited number of private rooms, and you should inquire about the availability of them if that is important to you. If you have specific care needs such as dietary restrictions, feeding tubes, respiratory therapy etc., you should discuss this with the admissions staff prior to admission as well.
The key to a successful transition to a nursing facility is to do a little homework first. Doing so could prevent some unwelcomed surprises later.
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Bradford A. McCoy, Administrator
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