Nursing Homes

August 3, 2010

Nursing homes, also known as skilled nursing facilities, care for individuals who require 24-hour nursing supervision.

There are two types of care provided in nursing homes:

  • Skilled Care (also known as “sub-acute” or “Medicare occupancy”)
  • Long-Term Care (also known as “Intermediate Care”)

Skilled Care entails services that can be rendered only by a doctor, licensed nurse, physical therapist, occupational therapist, speech and language therapist, social worker or respiratory therapist. It usually follows a hospital visit involving a short-term stay, during which the patient receives nursing care and/or therapy until he or she is stable enough to return home. Due to the skilled nature of the care, it is covered by Medicare and secondary insurance for up to 100 days. Beyond that length of time, it must be paid for privately.

Long-Term Care is appropriate for the individual who can no longer take care of him or herself and will continue to require a high level of care for the remainder of his or her lifetime. Such care may include help with any “activity of daily living,” such as bathing, dressing, transferring (moving from one place to another), toileting, eating and walking. Medicare does not cover this type of care. However, when the individual’s financial resources are exhausted, the state-funded source (Medicaid) will supplement the cost. If the nursing home does not accept state funding, you must find another long-term care facility that will. Unfortunately, most nursing homes have waiting lists for people entering the facility under state funding. Planning ahead with an appropriate strategy may help the patient and family avoid these conflicts.

How do I know which nursing home to choose?
The Centers for Medicare and Medicaid Services (CMS), the government agency that administers these medical-assistance programs, has developed a database of information on every Medicare- and Medicaid-certified nursing home in the country, including more than 17,000 nationwide.

To help people search for a nursing home that meets their needs, the CMS has developed Nursing Home Compare, an interactive tool that allows Medicare beneficiaries and their caregivers to compare information among all the nursing homes on the list. Nursing Home Compare enables you to search for nursing homes based on:

  • Nursing home characteristics such as number of beds, type of ownership and whether or not the nursing home participates in Medicare, Medicaid or both.
  • Resident characteristics including percent of residents with pressure sores, percent of residents with urinary incontinence and more.
  • Summary information about nursing homes based on their last state inspection (periodic inspections by state licensing agencies are required for Medicaid certification).
  • Information on the number of registered nurses, licensed practical or vocational nurses and nursing assistants in each nursing home.

What do I look for in a nursing home?
The Centers for Medicare and Medicaid Services (CMS), the agency that administers Medicare and Medicaid, also certifies individual nursing homes for inclusion in these government medical-assistance programs. The CMS has developed a detailed checklist for rating different nursing homes visited based upon:

  • Quality of Life
  • Quality of Care
  • Nutrition and Hydration
  • Safety

The Nursing Home Checklist (Adobe Acrobat Reader is required to view this file.) is a useful tool when you are investigating possible homes and want to keep track of the capabilities and characteristics of each home you visit. It guides you through a point-by-point review of every aspect of a nursing home, from basic information about Medicare or Medicaid certification and special services offered to the comfort and attractiveness of furnishings (in other words, if your combined income and financial assets fall within certain limits). The categories the checklist makes note of include:

  • Basic information about the facility
  • Resident appearance
  • Living spaces
  • Staff
  • Residents’ rooms
  • Hallways, stairs, lounges and bedrooms
  • Menus and food
  • Activities
  • Safety and care

How do I pay for nursing home care?

  • Medicare: Under certain limited conditions, Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, you must receive the services from a Medicare certified skilled nursing home after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just prior to entering a nursing home. This is at least three days. To learn more about Medicare payment for skilled nursing home costs, contact your Medicare Fiscal Intermediary or the State Health Insurance Assistance Program (SHIP) in your State.
  • Medicaid: Medicaid is a State and Federal program that will pay most nursing home costs for people with limited income and assets. Eligibility varies by State. Check your State’s requirements to learn if you are eligible. Medicaid will pay only for nursing home care provided in a facility certified by the government to provide service to Medicaid recipients. For more information about Medicaid payments, call the SHIP for your State or call your State’s Medicaid office. The telephone number is in the blue pages of the phone book.
  • Personal Resources: About half of all nursing home residents pay nursing home costs out of their own savings. After these savings and other resources are spent, many people who stay in nursing homes for long periods eventually become eligible for Medicaid.
  • Managed Care Plans: A managed care plan will not help pay for care unless the nursing home has a contract with the plan. If the home is approved by your plan, learn if the plan also monitors the home for quality of nursing care.
  • Medicare Supplemental Insurance: This is private insurance. It’s often called Medigap because it helps pay for gaps in Medicare coverage such as deductibles and co-insurances. Most Medigap plans will help pay for skilled nursing care, but only when that care is covered by Medicare. Some people use employer group health plans or long-term care insurance to help cover nursing home costs.
  • Long-Term Care Insurance: This is a private policy. The benefits and costs of these plans vary widely. For more information on these plans, contact the National Association of Insurance Commissioners (NAIC). It represents state health insurance regulators and has a free publication called “A Shopper’s Guide to Long-Term Care Insurance.” You also can get a copy of the Guide to Health Insurance for People with Medicare by calling 1-800-MEDICARE.
  • Counseling and Assistance: SHIPs have counselors who might be able to answer your questions about how to pay for nursing home care, the coverage you may already have, or whether there are any government programs that will help with your expenses.

Source: Center for Medicare and Medicaid Services, U.S. Department of Health and Human Services, Paying for Nursing Home Care.

Where do I find a nursing home?
To search the Department of Health and Human Services database of more than 17,000 nursing homes that are Medicare- and Medicaid-certified, click here. Keep in mind that many nursing homes have Special Care Units (SCUs) that are designed especially for the care of people with Alzheimer’s disease and related dementias.

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