We are happy to help you make the most of your benefits and other source of income. While some benefits depend on your income and savings, not all help is linked to your current income. As your needs change, your entitlements may also change. If you prefer not to discuss your financial affairs with our staff, we will be happy to refer you to someone else who can help.
To cover the cost of care, a resident will often use one or a combination of the following payor types:
A private pay resident is one whose primary cost of care, including the basic room rate as well as all other services not provided in the basic rate, is paid for out-of-pocket by the resident using personal funds and assets.
LONG TERM CARE INSURANCE
A long-term care policy pays a specified amount for nursing home care for a specified number of years in one’s lifetime. It’s designed to help supplement your care and protect your assets by paying for the expenses – the amounts set in your policy.
OTHER INSURANCE COVERAGE
Medigap and employer-provided or private health insurance plans can offset the cost of skilled nursing and long term care.
HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
If you are covered by a Health Maintenance Organization (HMO), skilled nursing care is managed through your insurance company. Please refer to your specific HMO plan for coverage and benefit information. You will be responsible for charges not covered by your HMO policy or other third party payors.
VETERAN’S ASSISTANCE PROGRAMS
The Veteran’s Administration (VA) provides payment for skilled and long term care, or both, to veterans in nursing homes and domiciliary care facilities. The length of VA contracts varies based on the individual. Contact the nearest Veteran’s Administration for more information regarding veteran benefits.
Medicaid is a cooperative federal-state program designed to provide health care services to low-income individuals. Included in these health care services is nursing home care, if the nursing home is certified to participate in the Medicaid program. The Resident will be held responsible for all services not covered by Medicaid or other third party payors.
If your income and assets are limited, you may qualify for Medicaid, which does cover most of the costs of nursing home care.
Medicare is a federal health insurance program that consists of two main parts for hospital and medical insurance (Parts A and B) and two additional parts that provide flexibility and prescription drug coverage (Parts C and D). If eligible, and if your healthcare provider participates in the Medicare program, Medicare helps cover specific costs of care.
The Medicare program is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the United States Department of Health and Human Services. When a Resident applies for Medicare, the application requires a full and complete disclosure of the Resident’s financial income and resources.
Medicare only covers limited stays in nursing homes for eligible residents. Skilled nursing or rehabilitation services are covered for a period of about 100 days after a hospitalization. Medicare does not cover custodial care (such as assistance with feeding, bathing, and dressing), if that is the only care needed.
Eight of the ten basic Medigap policies (Medigap Plans A-J) completely cover days 21-100 skilled nursing coinsurance; Medigap Plans K-L cover a portion. Three states have their own Medigap plans. In Massachusetts, the core plan does not cover skilled nursing facility coinsurance, but a supplemental plan does. Skilled nursing facility coverage is provided in Minnesota both with the basic and extended basic plan and in Wisconsin with the basic plan.
MULTIPLE BENEFIT SOURCES
If you have multiple benefit sources, such as Medicare and other health insurance or coverage, each type of coverage is called a “payor.” When there is more than one payor, “coordination of benefits” rules decide which one pays first. The “primary payer” pays what it owes on your bills first, and then sends the rest to the “secondary payer” to pay. In some cases, there may also be a third payer.
The insurance that pays first (primary payor) pays up to the limits of its coverage.
The one that pays second (secondary payor) only pays if there are costs the primary insurer didn’t cover.
The secondary payor (which may be Medicare) may not pay all the uncovered costs.
If your employer insurance is the secondary payor, you may need to enroll in Medicare Part B before your insurance will pay.
MANAGED CARE ORGANIZATION (MCO) BENEFICIARIES
Managed Care policies cover everything that Medicare covers. Sometimes there is a co-payment, however, for days 21-100, that is usually about half the cost. In addition, no prior hospital stay is required.