caremom1 Asked July 2010

I am confused about Medicare, Medicaid and Private Insurance benefits. Where do I start?

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My mom is in skilled nursing, will need transfer to another one long term. She has a good private health insurance through AARP, no long term care insurance and can't return home to live due to medical issues that have developed since a stroke. She has recently developed pneumonia as well.

I keep hearing about "100 days" and a patient is out of skilled nursing with medicare. Medicaid sounds like a nightmare, financially and other wise. We live in California and I don't even know where to start with the idea of what to do next.

Any experience with this? Suggestions?
Thanks!

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EXPERT K. Gabriel Heiser Jul 2010
Hi: I discuss this in my book:

Medicare Coverage of Nursing Home Expenses

Many clients are under the mistaken impression that Medicare will cover their long-term nursing home stays. If you give seminars or in client meetings, it is important that you educate the lay public about this.
In order for Medicare to cover a person’s nursing home stay, the patient must:
1. Have been hospitalized for medically necessary inpatient hospital care for at least 3 consecutive days, not counting the date of discharge,
2. Be admitted to the nursing home within 30 days after the date of discharge from the hospital,
3. Require skilled (as opposed to custodial) nursing or rehab care on a daily basis for a condition for which the patient was hospitalized, and
4. Receive a physician’s order that such care is needed.

Skilled Care. Skilled care is care that can only be administered by professional (physician or nurse) or technical personnel and which will prevent further deterioration in the patient’s health. Examples are intravenous feeding, injections, insertion of catheters, application of sterile dressings, treatment of skin ulcers, and therapeutic exercises of various kinds. Less medically intensive and critical personal care services, even if done by a nurse, are not considered skilled care.

100-Day Limit. Once in the nursing home, the patient will only be covered by Medicare for a maximum of 100 days during any spell of illness. A “spell of illness” means a period of consecutive days beginning with the first day (not included in a previous spell of illness) on which such individual is furnished inpatient hospital services, inpatient critical access hospital services or extended care services, and which occurs in a month for which he is entitled to Medicare Part A benefits, and ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of a nursing facility.

Co-Pay Rule. Finally, even if the patient manages to qualify for Medicare coverage of their nursing home stay, Medicare only fully pays the bill for days 1-20. For days 21-100, Medicare only pays the “SNF care coinsurance” amount, which in 2010 is $137.50 (set annually by the federal government).
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Hope that helps!
K. Gabriel Heiser
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lt7481 Jul 2010
Could someone please address the pros and cons of applying for medicaid. my mother has medicare and AETNA and is being advised to apply for medicaid. Please advise. Thank you.
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lt7481 Jul 2010
thank you
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caremom1 Jul 2010
Mr.Heiser-
Thank you for taking the time to respond. My mother contracted pneumonia ,swollen right extremities and developed skin ulcers in the nursing home.Mild heart failure was diagnosed on the Xray which showed no progress was being made with curing the pneumonia. So, my mom started out in the facility because of rehab needs after a stroke and now there are many complications to both general health and viable rehab progress.
Does she need to be reevaluated and diagnosed with multiple needs for"skilled" nursing?
If she left skilled nursing, went back to the hospital for 4 days for heart failure then back to rehab would the 100 days start again?
Any suggestions are very much appreciated.
Thanks again for sharing your expertise.
Kim(caremom1)
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lanninge Feb 2012
My 89 year old mom just went in a nursing home after being in a hospital for a week.She has aarp and medicare A and B.If she stays long term,how will it be payed.Her house was put into three sons name four or five years ago. She has no assets
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Each state has their own Medicaid program. Look up Medicaid in your state. Also, social services may be able to help you. Good luck!
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cmeyers Feb 2014
I too am having the same problem with all the new changes going on...not sure where to begin. I did find this booklet on the Medicare site: http://www.medicare.gov/pubs/pdf/10050.pdf ...covers a how the system works and types of coverage. I have not been able to read through all of it but plan to. As far as the plans and pricing goes, I found a comparison tool on www.joppel.com . You can input your location and and specific coverage needs and it will show you all the plans available in your state. I need all the help I can get with this topic. Wishing you luck as well.
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Medicare and medicaid are government programs that helps you pay for long term care expenses, private insurance as the name suggest is from private companies who offer long term care insurance.
Medicare does not pay for long term care, but rehabilitative care in a skilled nursing facility and is limited to 100 days only. You can take advantage of the first 20 days because medicare pays every cent of your expense but after 20 days, you need to shoulder some of your expenses until the 100 day period. After 100 days, you will shoulder all your expense out of pocket. To be able to qualify for medicare, you should be 65 years old or above, but if you have disability or kidney disease, you still qualify for medicare even if you are younger than 65.
Medicaid is a program that pays for long term care expenses, however, you should pass a poverty criteria to qualify. The poverty criteria depends on the state where you live. Although medicaid covers your expenses for long term care services, they have an asset-recovery procedure, in the event that an individual under medicaid program dies, their property will be subjected to this procedure so medicaid can recover the expenses incurred for the person's ltc services.
Private insurance on the other hand offers long term care insurance to finance your long term care needs, however, if you already have an illness, you might be declined. You cannot insure a person who is already ill just as you cannot insure a house that is already burning.
There are other government programs that helps pay for long term care needs, you just need to better understand the requirements so you can qualify. You can get additional information about other government programs here: http://www.infolongtermcare.org/ltci-learning-center/what-is-long-term-care-insurance/government-long-term-care/
Or check the federal programs for LTC here:
https://www.ltcfeds.com/
For other information about medicaid program, check here:
http://longtermcare.gov/medicare-medicaid-more/medicaid/
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