As people age, the probability that they will need long-term care in a nursing home increase. Most Americans over the age of 65 rely on Medicare insurance to cover their health care costs. Unfortunately, Medicare coverage does not extend to long-term nursing home care and many people find themselves paying out-of-pocket.
If you or a loved one are Medicare recipients and facing the possibility of needing nursing home care, it is important to know all your insurance options ahead of time. If you do not have the financial means to pay out-of-pocket for nursing home care after your Medicare coverage ends, you may be able to get help from Medicaid.
Medicare Coverage for Nursing Home Care
Medicare recipients have coverage for skilled nursing care lasting up to 100 days for every separate instance of an illness or injury. In order to be eligible for coverage, you must stay in a Medicare-approved facility, you must be admitted within 30 days of a hospital stay which lasted for three days or more, and you must have an order from a physician stating that you require treatment. The physician must certify that you need skilled nursing care to maintain or to slow the deterioration of your current status of health.
Medicare covers the cost of skilled nursing care, rehabilitative services, a semi-private room and meals, plus any medical supplies needed for treating your prescribed condition. It does not cover the cost of custodial care like bathing, feeding, or dressing.
Medicare pays 100 percent of skilled nursing facility services for the first 20 days. On days 21 through 100, the beneficiary is likely responsible for a copayment. As of 2019, the copayment is $170.50 per day. If you have a Medigap policy, it may help cover copayments. After 100 days, the beneficiary may be responsible for 100 percent of all costs.
If you are looking at long-term nursing care, the costs can add up very quickly. So, what happens when you no longer have the means to pay for your nursing home costs? If you are eligible for Medicaid, you may get some help.
Who is Eligible for Medicaid Coverage?
In the United States today there are over 10 million people who receive both Medicare benefits and Medicaid services. People known as dual-eligibles meet federal qualifications for Medicare and their state’s qualifications for Medicaid.
Depending on your personal situation, you may qualify for either full dual-eligible coverage, or partial dual-eligible coverage. With full coverage, Medicaid may pay for services that are not covered by Medicare. With partial coverage, Medicaid may pay Medicare premiums and other cost sharing depending on the program you qualify for.
The qualifications are different for each state, but most states follow the federal Supplemental Security Income (SSI) income and asset guidelines. You may qualify for full dual-eligible coverage if your income is 300 percent of the SSI income limit or less. As of 2019, the SSI income limit is set at $771.00 per month. Calculating 300 percent of that gives you an income limit of $2323.00 per month. In states using the SSI regulations, there is a $2000.00 limit on countable assets per individual. That amount goes up to $3000.00 when both members of a married couple are getting care.
Because each state has its own regulations regarding resources and income allowances concerning partial dual-eligibility coverage, be sure to check with your local Medicaid office to see if you meet the requirements.
Does Medicaid Help Pay for Nursing Home Care?
For people who are dual-eligibles, any health care services they receive are first covered by Medicare and then Medicaid takes over. For full dual-eligible beneficiaries, Medicaid services provide coverage for care given in certain types of facilities. These facilities must accept Medicaid payment and your health care provider must certify that it is medically necessary for you to be admitted. These facilities include:
• Nursing homes
• Intermediate care facilities
• Long-term care institutions
If you are already receiving Medicaid, be sure to check your eligibility status for nursing home coverage as it often varies from other types of coverage.