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 Rockland
- We all want to age in place in our own homes, on our own
terms -- any place other than a nursing home. Sometimes
situations change quickly, however, and for a number of
reasons it just may not be possible to remain safely in the
community. It is at these times of crisis that folks often
discover that all the ideas they had about their long-term
care security and how they would pay for nursing home care
if needed are basically … well, wrong. There are five major
payment sources for nursing home care, each worthy of its
own full-length column, but I offer the following brief
summary to help dispel some of the myths on this topic.
The most common misconception I hear from seniors is that
Medicare is going to cover all of their nursing home costs.
This simply is not true.
Medicare
Medicare will only cover “skilled” care, and only if all
of the following conditions are met:
• You have Medicare Part A (hospital insurance) and
have days left in your benefit period.
• You have a qualifying hospital stay, which is an
inpatient stay of three consecutive days or more, starting
with the day of admission and not including the day of
discharge. (Alert: If you are held for “observation” for
part of your hospital stay prior to being admitted, you may
not have met the minimum requirement. This is an issue that
should be promptly appealed).
• Discharge to a rehabilitation facility either
directly or within 30 days.
• Your doctor orders the services you need for Skilled
Nursing Facility (SNF) care, which require the skills of
professional personnel such as registered nurses, LPNs,
physical, occupational, and speech therapists, and are
furnished by or under the supervision of these skilled
personnel.
• You require the skilled services on a daily basis
(five days per week qualifies).
• Medicare will pay the full cost for days 1- 20, and
you will be responsible for a significant daily copayment
from days 21-100. Medicare does not pay beyond the 100 day
period, unless you have a break in your coverage for at
least 60 days. In that case, with the above conditions met
again, you would have a new 100-day period available.
The availability of 100 days is not, however, a guaranteed
coverage period of 100 days. In fact, it is far from
guaranteed with the average period of SNF care covered by
Medicare being only 23 days. You must also qualify according
to the clinical criteria set forth by Medicare. Medicare
requires the facility to conduct periodic assessments of
your condition and goals to determine whether you will be
approved for extended skilled coverage.
(Alert: If you receive a Notice of Medicare Provider
Non-Coverage informing you that your Medicare coverage will
terminate because you have “reached a plateau,” “are
stable,” “custodial care” or not improving, consider filing
an immediate appeal.
If you need continued skilled services in order to maintain
your present condition, then you are entitled to continued
coverage under the Medicare Act and federal law.)
Veterans Benefits
Nursing home care is not automatically available to all
veterans enrolled in the VA health plan. Only the following
veterans automatically qualify for unlimited nursing home
care:
• Veterans who are seeking nursing home care for a
service-related condition.
• Veterans with a service-connected disability rating of 70
percent or more.
• Veterans who have a service-connected disability of
60 percent and are unemployable.
• A service-connected disability is a disability that
the VA has officially ruled was incurred or aggravated while
on active duty in the military and in the line of duty. The
VA must rule that your illness/condition is directly related
to your active military service, and it assigns each
disability a rating. The ratings are established by VA
regional offices around the country.
• The VA may provide nursing home care to other
veterans if space permits. Veterans with service-connected
disabilities receive priority.
Long Term Care Insurance
The popularity of long-term care insurance is growing,
for obvious reasons. The problem with this payment option,
however, is that many people don’t consider purchasing
long-term care insurance until they need it. When they need
it, they simply will not qualify for it. If you have not had
a diagnosis that would affect your ability to obtain
long-term care insurance, look into it today.
Even if you pay more for it based on your age, the
statistics show that your investment will be well worth it
down the road. In addition, there are tax incentives
available for purchasing long-term care insurance, and
certain qualifying policies can make your home a
non-countable asset for Medicaid/MassHealth purposes. Call
my office if you would like a referral to a trusted
insurance professional.
Private Payment
This is the most non-desirable payment option for
extended nursing home payment, but most folks do not do
adequate preplanning. Let me be clear, facilities provide
care, and facilities need to be paid for their services.
Pre-planning is critical, however, to ensure that you take
advantage of laws that allow you to protect your spouse and
protect your own quality of care for the future. Private
payment can average from $10,000-$12,000 per month – could
you afford to pay this expense for an extended period of
time without putting your spouse or your security at risk?
Have you taken the necessary steps to ensure that your
security will not be left to chance?
Medicaid
Medicaid is the federal program that is known as
MassHealth in Massachusetts. When you run out of funds to
pay for your nursing home care, you can apply for MassHealth
coverage. An individual may only have $2,000 in assets, and
a married couple may have a combined $111,560. There are
some assets that are “non-countable” in that limit, such as
the marital home, life insurance with a face value of $1,500
or less, a car, life insurance that you can not access or
surrender (such as a group or term policy).
There are a myriad of regulations that apply to specific
situations, and penalties imposed if you give your funds
away within the five years prior to applying for MassHealth.
It is imperative to do advance planning to ensure that you
apply the regulations to your particular situation in a
manner that will maximize your future security without
jeopardizing your eligibility for this important benefit.
This summary is far from comprehensive, but I hope it causes
you to reflect on your own situation.
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