Medicare (T 18), Medicaid (T19), Veteran's benefits, private insurance and personal assets are used depending upon various circumstances.
Medicare pays for skilled nursing care for a limited period of time following a 3 day hospitalization. This includes a semi-private room, meals, skilled nursing and rehabilitative services and other services and supplies. Medicare does not pay for "long term care". Skilled care as defined by Medicare is 'A level of care that must be given or managed by licensed health care professionals and is under the general direction of a doctor. All of your needs are taken care of with this type of service, including giving direct services. As long as you need skilled care, it makes no difference whether your illness is acute, chronic, or terminal. Any service that could be safely performed by an average non-medical person (or one's self), without the direct supervision of a licensed healthcare professional, is not covered.'
Also…
'The skilled nursing facility cannot make you pay anything to be admitted unless it is clear to you that Medicare does not cover the cost of services AND you must be told right away if the facility decides you do not need the level of skilled care covered by Medicare. If you disagree with this decision, you may ask the skilled nursing facility to submit something called a "demand bill" to Medicare.' Contact Medicare for more information on a "demand bill". (from "Medicare and You 2000")
Medicaid (T19) covers individuals in an institutional setting if the person is:
65 years of age or older or blind or disabled
A U.S. citizen, qualified alien or member of certain categories of asylees and refugees
Receiving care at a Medical Assistance (Medicaid) certified facility.
Receiving care at the 'skilled' or 'intermediate' care levels which is higher than custodial care levels. The care must be provided by a trained medical professional or by someone under the supervision of a trained medical professional.
The beneficiary must have monthly nursing home expenses greater than the monthly income and assets for a single person under $2000. Part of the cost of care is covered by the individual's income and the rest is covered by T19. If the stay is limited or there is the expectation to return home, ownership of a home is not a problem. However, if a single homeowner enters a facility with no expectation of returning home, the home may need to be sold or placed on the market before receiving financial assistance under Medicaid.
When a married person enters a nursing home, eligibility is established quite differently. A specified amount of the couple's combined income and assets are protected for the spouse remaining in the community. This is called "spousal impoverishment". The spouse remaining in the community may retain a significant share of the couple's marital assets and may even be entitled to receive income from the institutionalized spouse on a monthly basis. The Medicaid law is complex and changes frequently. If you have a spouse in a nursing home speak to the Social Worker for application for Spousal Impoverishment. For more information about assets, exclusions and Medicaid, contact your county's Benefit Specialist or an Attorney who specializes in Elder Law.
Currently in the State of Wisconsin, a number of nursing homes are requiring some private pay before accepting a person on Medicaid. While this is not legal, the State and Federal governments are allowing them to do so. Make sure you know what the requirements of the individual facility are.
For up to date information on Veteran's Benefits and current contracts with certain facilities, please contact the closest Veteran's center. Individuals with private health insurance need to contact that insurance company. Some companies have contracts with specific facilities and will only pay for care at those facilities. If care at a nursing home was initially covered under Medicare but for a number of reasons will no longer be covered, you may need to pay privately or use any long-term health care insurance previously purchased. If there is a spouse remaining in the community you should inquire about 'spousal impoverishment'. Again, the spouse remaining in the community may retain a significant share of the couple's marital assets and may even be entitled to receive income from the institutionalized spouse on a monthly basis.
Who Licenses and Regulates Nursing homes?
What are the types of licensed facilities and the type of care provided?
What does Title 19 NOT pay for?
Agencies or organizations that may be of additional assistance