Insurance Coverage- Understanding Your Options

 

Medicare is the federal government’s senior citizen (65 years or older) insurance policy. It covers Skilled Nursing care and/or Rehabilitative (excluding long term/custodial) services under Part A [and doctor visits and ancillary  services under Part B] up to 100 days after admission. The first 20 days are covered 100% in full by Medicare, from day 21 through day 100 there is $148.00 co-pay per day. This co-pay could be covered by either a Medicare supplemental insurance policy, Medicaid or paid privately. These 100 days will cover as the primary payor source ONLY if and as long as the resident is still receiving  “skilled care”. Examples of “Skilled Care” are: Physical, Occupational, Speech, Wound Care and/or IV Therapy. If resident has reached their pre-determined goals set forth by the interdisciplinary care plan team, or if resident has reached a point of max potential, or if resident chooses not to participate in the rehab services, even before 100 days expires …it is no longer justified or allowed for the facility to continue providing this skilled care and/or to bill Medicare. At this point and also if and when the full 100 days are about to be exhausted you will receive a “Notice of Medicare Non-Coverage” letter. This letter will explain the reason(s) and your rights of appealing this decision with IPRO – Medicare’s contracted intermediary to handle such  matters. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility policy is to offer and encourage the disenrollment option and convert resident to typical Medicare (where applicable). The process is much simpler dealing with Medicare as opposed to the private HMO companies who are constantly looking to cut and deny coverage.

 

If Medicare or HMO is no longer providing coverage, resident/designee has to decide whether they want to take resident home or continue on at the Nursing Home and pay privately ($400 per day) or apply for Medicaid – an income supplement. 

 

MEDICAID – is a State funded income supplement program for the “poor and indigent” population. They help pay for nursing home “room and board” charges. They ONLY pay (supplement) for what residents themselves cannot afford. They ask and expect residents to turn over their monthly income - Social Security and/or Pension - and they will pay the facility the difference. This income is also known as the NAMI=Net Allowable Monthly Income. Example: Resident has a monthly Social Security check of $250 and a Pension check of $200 and the facility bills $1,000 for the month…then the residents responsibility is to turn over their $450 monthly income and Medicaid will supplement and pay the rest - $550. Whether the facility is billing Medicaid as a Primary Payor source or as a secondary (Medicare co-pay days of 21- 100) this NAMI is asked and expected to be turned over in full. If/when there’s spouse, s/he gets to keep $2,898. 

 

* If and when a resident is here for Short Term only (less than 6 months) s/he gets to keep $800 of their monthly income towards rent in the community. All excess income is due to the nursing home. (If/when there’s spouse, they get to keep $2,898 like before). 

 

{Note: residents get to keep $50 from NAMI money as their monthly spending money. If full NAMI checks are sent in to the facility this $50 will be placed is their PNA=Personal NAMI (bank) Account here at the facility from which they could withdraw their money from at any given time}. 

 

When applying for Medicaid, a number of documents are needed for processing. Please reference “DOCUMENTATION REQUIRED FOR MEDICAID APPLICATION” and discuss/inquire with the facility’s Medicaid Coordinator what specifically pertains to your case. 

 

Medicaid Eligibility – the State Medicaid offices review your application, analyze and determine if you’re eligible. Residents are entitled to have and keep up to $14,500 in savings as a single person household ($115,000 for a married couple) and still be eligible. There are legal loopholes as well: 

 

• A resident is allowed to spend down their assets with an unlimited dollar amount pre-approved burial arrangement. 

• A spouse could sign a “Spousal Refusal” form indicating that s/he live in their shared (community) house and need their savings to live on and therefore “refuse” to pay for caring for their spouse. This is generally accepted by Medicaid. However, keep in mind, Medicaid reserves the right to investigate this claim. 

 

Please be sure to speak with Hindy Scher, our Admissions Financial Coordinator for more information on this and any other questions you might have. She can be reached at 718-567-2644.