Who Is Going To Pay for This?

Medicaid is a health payment plan for needy individuals.  Unlike private health insurance, Medicaid will pay for many of the costs associated with long-term care, such as care in a nursing home or assisted living residence or a home health aide at home.  Private health insurance does not pay for these forms of care.

Long-term care is considered to be custodial care, not restorative or rehabilitative care.  In other words, when a person is receiving long-term care, the goal is not to make the person better.  The goal is to care for a condition that is not expected to improve.  In fact, the condition is often expected to worsen.

The most common scenario of a person entering a nursing home begins with a stay in the hospital.  The patient normally has a traumatic event, such as a fall at home, that results in a traumatic injury, such as a broken hip.  The patient then is sent to the hospital to repair the broken hip.  After the stay in the hospital, the patient will frequently be sent to a nursing home for rehabilitation of the broken hip.

Many people tell me that their family member is not in a nursing home.  She is in a “rehab center.”  Most rehabilitation centers are nursing homes.  Most nursing homes have a section for rehabilitation patients and a section for custodial patients, but all of the patients are in one building and that building is a nursing home or a nursing facility.  There are very few pure rehabilitation facilities.  I know of only three in this area of the state.  So, if your family member is receiving rehabilitation in a facility, then she is probably in a nursing home.

Most of the people whom I help are older than sixty-five years of age.  Most in-patients in nursing homes are older than sixty-five years of age.  So, most of these people are Medicare beneficiaries.

Medicare is a health insurance program for senior (older than sixty-five years of age) or disabled individuals who have paid into the Medicare program.  Unlike Medicaid, Medicare will not pay for long-term custodial care.

With respect to rehabilitative services, Medicare will pay for a maximum of 100 days of rehabilitative services per spell of illness.  The 100 days is a maximum, not a guarantee.  A patient may—and frequently does—receive far less than 100 days of coverage.  The only guarantee is that the patient will receive no more than 100 days of coverage.

So, while a patient is within the 100 days of coverage, Medicare will pay for the costs associated with the nursing home, subject to certain co-payment requirements depending upon how long the services last (and they will last no longer than 100 days).  Once Medicare coverage ends, the patient must either go home or become a long-term custodial patient in the nursing home.

If the patient becomes a long-term custodial patient, then they must either pay privately for their care (at the cost of $10,000 to $14,000 per month) or qualify for Medicaid benefits.  Many people come to me hoping to qualify for Medicaid.

Medicaid is a needs-based program.  In order to qualify for Medicaid, the individual must have very limited assets (typically less than $2,000) and insufficient income with which to pay for her care.  The application for Medicaid is filed with the county board of social services for the county in which the patient currently resides.  In other words, the county in which the nursing home in which she is a patient is located.

Applications for Medicaid benefits are, by law, supposed to be processed in forty-five days, but my experience is that the application takes anywhere from four to six months.  An application for Medicaid is essentially a forensic examination of the person’s finances for the past five years.

Comments are closed.