Medicaid versus Medicare: Who Covers Nursing Home Costs?

Because a stay in a nursing home may be covered by either Medicare or Medicaid, it can be confusing to determine which program will cover your family member's stay. While both programs may indeed cover at least some portion of a visit to a nursing home, there are important differences to the rules.

Medicare coverage of nursing home costs
In order for Medicare to cover a person's nursing home stay, the person must:

• Have been hospitalized for medically necessary inpatient hospital care for at least three, consecutive days, not counting the date of discharge,
• Be admitted to the nursing home within 30 days after the date of discharge from the hospital,
• Require skilled nursing or rehab care on a daily basis for a condition for which the patient was hospitalized, and
• Receive a physician's order that such care is needed.

The difference between skilled care and custodial 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 include: intravenous feeding, injections, insertion of catheters, application of sterile dressings, treatment of skin ulcers, and therapeutic exercises of various kinds (physical therapy). Less medically-intensive and critical personal care services—even if performed by a nurse—are not considered skilled care.
If the care the patient requires is not considered "skilled care," as defined above, such care is called "custodial care." This is the type of long-term care is typically received in a nursing home. Only Medicaid—not Medicare—covers custodial nursing home care.

The co-pay rule
Medicare will only cover a patient for a maximum of 100 days (per separate spell of illness), if it covers the patient at all. During days one to 20, Medicare will cover the entire cost of the nursing home stay. For days 21 to 100, the patient must pay a co-pay, which is currently set at $152 per day. If care is needed beyond the 100-day limit—or if patient no longer needs skilled or rehab care before 100 days have passed—then the patient must either pay privately, be covered by some form of insurance or qualify for Medicaid.

Medicaid rules for skilled nursing payments
Medicaid is a "needs-based" program, meaning that the patient cannot have more than a certain minimal amount of assets and income in order to be covered. Medicare, on the other hand, is available regardless of the patient's income or assets, if they meet the other requirements. Also, there is no mandate that a patient require skilled or rehab care in order to be covered by Medicaid, as there is for Medicare. To find out the asset and income limits in order to qualify for Medicaid, see "Assets You Can Have to Still Qualify for Medicaid" and "How Can My Elderly Loved One Qualify for Medicaid?"

A note about dual-eligibles
Finally, keep in mind that it is possible to be covered by both Medicare and Medicaid, simultaneously. Such individuals are known as "dual eligibles." For these elders, Medicaid covers those expenses not covered by Medicare, such as paying the Medicare premiums and cost-sharing requirements and paying for long-term custodial care, while Medicare would cover hospitalizations and related medical costs along with skilled care in a nursing home.

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Medicare and the ACA

Medicare and the ACA

Amid the ongoing rollout of the federal and state health insurance exchanges, it is important for seniors and caregivers alike to understand how Medicare fits with the Affordable Care Act (ACA).

It is an important time to understand the changes to the Medicare plans, now that open enrollment has ended, and you continue to help your loved ones make critical health decisions. Health Care Service Corporation (HCSC), the largest customer-owned health insurer in the United States, would like to help you understand the implications of the ACA on seniors, and the added benefits seniors can expect to receive.

Since Medicare is not a part of the Health Insurance Marketplace established by the ACA and Open Enrollment for Medicare coverage remains the same, seniors were not required to do anything different during enrollment. That said, the ACA provides many new benefits for seniors as it expands the Medicare coverage that they already have, including:

• Additional preventative benefits available.
  Seniors can work closely with their doctor to set up a prevention plan that will include wellness visits and screenings for diabetes, certain cancers, mammograms, colonoscopies and more.
• Improved primary care.
  Initiatives to ensure primary care providers are available to give seniors quality care. Doctors may receive additional resources or incentives to verify that treatment is consistent.
• Savings on brand-name prescription drugs.
  Many seniors fall into the “doughnut hole” when they have prescription drug coverage under Medicare Part D and fall into the coverage gap. The new law will provide a 50 percent discount on prescriptions during 2014 and begin to close the gap.

Still, as is common each year, insurance companies will update and revise their Medicare products, which can often lead to changes in the providers, products and services available for a given coverage level.

While the Annual Enrollment Period (AEP) for certain Medicare products ended December 7, seniors turning 65 can still review Medicare coverage options throughout 2014. By spending time in advance, seniors and their caregivers to can help to ensure they are utilizing all of the benefits that Medicare has to offer. Seniors should take time to consider what is important to them, such as additional services that include wellness visits and diabetes screening, how to make the most of their prescription coverage, and selecting the best doctor for their specific health needs.

We hope these services will help make it easier for you and your loved ones to find additional value in Medicare coverage and enable a healthy 2014. For more information, visit Medicare.gov.

Health Care Service Corporation is the largest customer-owned health insurance company in the United States. HCSC offers a wide variety of health and life insurance products and related services, through its operating divisions and subsidiaries; including Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma, and Texas, and through Dearborn National.

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How to Save Money on Prescription Drugs

Not paying attention to where you're buying your prescription drugs could cost you—to the tune of $100, or more, says a new Consumer Reports analysis.

Secret shoppers posing as uninsured consumers called 200 pharmacies nationwide in order to uncover the cost of a month's supply of each of the five popular prescriptions that recently went generic: Lipitor, Plavix, Lexapro, Singulair, and Actos.

Costco proved to be the most cost-effective for consumers overall. The wholesaler's pharmacies offered a 30-day supply of Lipitor for $17, Lexapro for $7, and Plavix for $15.
On the other end of the spectrum, shoppers who went to CVS risked paying up to five times more for some prescriptions. CVS charged $150 for a month's worth of Lipitor, $126 for Lexapro and $180 for Plavix.

Why such a huge price difference for the exact same bottle of pills?
It all depends on how important the pharmacy is to a store's overarching business model, Lisa Gill, a prescription drug editor for Consumer Reports explained in a company press release.
For example, a big-box wholesaler who boasts a wide product offering that ranges from chicken breasts to flat-screen TVs is likely aiming to entice consumers with their low-cost pharmacy, with the hopes that they will purchase other items.

How to Save Money on Prescription Drugs

• Medicare will help cover the cost of an older adult's prescription medications, but the program won't pay for everything. (Learn what is and is not covered by Medicare, as well as the pros and cons of Medicare coverage)
• Once you factor in monthly premiums, the plan's deductible and the various co-payments involved, the cost of prescription medications can quickly add up.
• Given that many of these men and women take at least half a dozen different prescriptions to help them manage everything from heart disease to diabetes, finding ways to keep medication costs down is vitally important for seniors and their caregivers.

Consumer Reports offers a few strategies for taming medication costs:

• Opt for generics: Generics can be an extremely cost-effective alternative to brand-name drugs, if a senior can tolerate them. The patents preventing many popular senior medications from being able to be produced generically have recently expired. Talk to your loved one's doctor to see whether any of their prescriptions can be swapped for generics.

• Buy in bulk: People taking long-term medications (i.e. Lipitor to manage high cholesterol) may be able to reduce their costs by buying a 90-day supply versus a 30-day supply. Most retailers offer discounts for those who can purchase pills in bulk.

• Ask for a lower price: Many of Consumer Reports' secret shoppers weren't provided with the lowest price for a particular drug right away, they had to dig a bit deeper and inquire about discounts and special offers before they hit upon the best price. Don't be afraid to negotiate and try to unearth the best price for a given medication. According to Gill, "A consumer can't assume that the price of their prescription medications is set in stone. One of the big takeaways is that you have to ask for the best price and see if your pharmacist will work with you."

• Don't shun mom and pop drug stores: People assume that chain retailers automatically present the most cost-effective options when it comes to most items, including prescription medications, but Gill says this isn't always the case. Independent pharmacies have an incentive to maintain a solid relationship with their customers, she says. Thus, they are more likely to help their regulars get the optimum price for their prescriptions.

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How the Healthcare System Can Work Against You

Administering the best possible care (i.e., changing dressings daily, using the most appropriate medications and providing other necessities) may be very costly. Such care may not be covered by your insurance policy. You will almost certainly have out-of-pocket expenses for things that are not considered "medically necessary."

Instead of providing greater coverage, having two insurance policies could actually mean less coverage. Each plays against the other -- delaying or actually curtailing benefits. Make sure you have a clear agreement as to which payer is "primary."

A spouse is legally responsible for the partner's bills and his/her income is included in determining Medicaid eligibility. Unmarried couples are considered as single individuals, making it easier to get Medicaid benefits, which may include home care.

If someone tells you "Medicare (or another insurance) won't pay for it," don't stop there. Check it out yourself through your State Health Insurance Assistance Program, the Medicare Rights Center at (212) 869-3850 or online at www.medicarerights.org, or through another independent source.
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Health Care Coverage: Knowledge is Power

Most people - whether as patients, family caregivers, or health professionals - do not have a good idea of what medical insurance (assuming the patient has some) will pay for until the need arises. Family members and patients are often shocked to find that insurance will not pay for many services and items needed at home that are routinely paid for in the hospital. Unless your relative has specific long-term care insurance (and very few people do at this point), many home care needs, especially home care aides or attendants, will not be covered at all or beyond an initial short-term period.

 

Here are a few suggestions:

 

• If your loved one has been hospitalized, insist on being consulted by the discharge planner about the care plan before decisions are made. Explore all the options, not just the one the discharge planner recommends.
• Find out what your insurance company will approve for your loved one's care, why, and for how long.
• Try to get one person from the insurance or managed care company (a case manager) assigned to your loved one's case and make sure that person fully understands the patient's condition so that the correct home care services and equipment are provided.
• Look out for inconsistencies or vaguely described benefits. Do not let your insurance company deny coverage for something that has been covered in the past or that you believe should be covered.
• Keep detailed records of phone conversations and personal contacts about the case. Write down whom you spoke to, what they said, and when they said it. Insurance coverage decisions are often flexible. You may need to document interpretations you have been given by different people.
• If there is a home care nurse or aide assigned by an agency, make sure that person is experienced with your loved one's care and can handle the physical, behavioral, and technical aspects.
• Make sure you have been assigned the correct level of home care assistance. Registered nurses, practical nurses, and home health aides or personal care workers have different skills and limitations. There are also different types of agencies, only some of which are Medicare - Medicaid certified.

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