This site is best viewed using Mozilla Firefox browser.

Senior Living

2010-12-01 11:33:00

Medicare vs. Medicaid

Question: My friend’s mother doesn’t have enough money to pay for nursing home care and yet he was told that Medicare won’t pay for her. Why not?

Answer: Well, I don’t know your particular case, but I would suspect he may be getting Medicare and Medicaid mixed up. Medicare as used in a nursing home is only for someone who qualifies because they have been in a hospital for the required days and must have what is referred to as skilled nursing care. They must also have Medicare A insurance, which they have to pay for, and either enough money to cover the co-pay or a “medi-gap” insurance policy, which covers the difference between what Medicare pays and the balance of the bill or they must have what is known as a Medicare Advantage Plan. Medicare can seem real complicated. It can get very complicated when a Medicare Advantage plan is used instead of a Medicare, medi-gap policy combination, only because each plan is different. The simplest form of Medicare, at least for us in the nursing home profession to deal with, is the government issued Medicare A policy and a privately issued medi-gap policy. In that case, the government i.e. the Medicare program pays for required “skilled” care for the first twenty days of a nursing home stay and them requires co-pay for the next 80 days. However, to get that payment, the resident must “qualify” for Medicare A payments. They must also not have used up some of those days previously within the same qualification period or their benefit will be decreased by that many days. Remember, this is a government program! We are only going to talk about the use of Medicare A in nursing homes here, and then only touch on it lightly. To deal with it in detail would require a very thick book. The first qualification for Medicare A in a nursing home is the resident must have had a three night qualifying stay in a hospital. That means they must have been admitted to the hospital for a reason that will require “skilled” follow-up care in a nursing home. One of the problems we are seeing with the use of Med A for residents is that many times hospitals bring a person in for “observation” rather than “admitting” them. That precludes the use of Med A in the nursing home. If the resident is admitted to the hospital for the required three-night stay, then it must be determined if they require “skilled” services in the nursing home. While it can be complicated on what the requirements are, basically, it means that if the resident requires therapies or specialized nursing services, because of the hospital stay, then they can qualify for Medicare A in the nursing home While Medicare A, will pay for up to 100 days, they seldom do because the specialized services usually aren’t needed that long. When the resident no longer needs the “skilled” services, whatever they were, then Medicare A will cease payments. The resident then must pay for their stay out of their own pocket, unless they have long term care insurance or they previously have been admitted to the Medicaid program which provides financial assistance for nursing home care to those who are unable to pay for it themselves.. The real issue here is that you must fill out an extensive application for Medicaid and be found in need. The folks at SRS, who receive these applications, are very very busy trying to take care of everyone. Oftentimes there is a wait, not because they don’t want to help you, but they are just so overburdened with applications. Even if you are admitted to the Medicaid program, it does not mean that all of your nursing home care will be paid for. The program will assist in the payment of the costs, but in many cases there is a “resident liability” based on the resident’s assets. Medicaid takes into account all income and assets while calculating how much they will assist in the payments for nursing home care. If the original question was: Will Medicare pay for my mothers nursing home care and if she wasn’t in the hospital? The answer was probably a no. However, many people get Medicare and Medicaid mixed up. Maybe your friend should have been asking if Medicaid would help pay for his mother’s care. To find out if Medicaid can assist in his mother’s care he should contact SRS at 316-337-7000.