Consumers

Topics in this Section:

• Paying for Long Term Care
• Medicaid Eligibility For Nursing Home Benefits
  Medicaid Eligibility Information from NC State University; A comprehensive guide for North Carolinians.
• Medicaid Eligibility Slide Show
  A broad overview of the issues involved in qualifying for Medicaid Benefits.
• How to Pay for Long Term Care
  Information from the American Heath Care Association.
• North Carolina Medicare Part A
  A web site describing how Medicare works in North Carolina

Paying for Long Term Care

Once the decision is made to enter a long term care facility, one of the early considerations is how the stay will be financed. With costs up to and over $100.00 a day, paying for long term care from personal funds can be very expensive. Nursing facility costs are much less than hospital charges, but insurance payments for nursing home care are often very limited. When compared to the cost of a fancy hotel room, the cost of a nursing home day is reasonable considering it covers 24 hour nursing care, all meals, activities, and utilities.

PAYMENT SOURCES

Not all facilities accept payment from the various insurance programs. In order to receive payment from Medicare, Medicaid, and Veterans Administration Benefits, facilities must enter special contractual agreements with various government agencies. The paperwork and other requirements often make it undesirable for facilities to participate in these programs. Before a resident is admitted to a nursing facility, the source of payment must be determined and agreed upon.

MEDICARE PART A

Strict coverage guidelines result in Medicare Part A (Major Medical) paying for only about 10% of nursing home stays. If coverage is approved under Part A, Medicare pays for most medical expenses during the first 20 days. A large co-insurance payment by the resident is required for the next 80 of the maximum 100 days. If purchased, Medicare Supplemental insurance will pay an additional amount toward the co-insurance payment required starting on the 20th day.

MEDICARE PART B

Even though the nursing facility room and board is not paid for by Medicare Part A, therapies and other services may be paid to the government to have Part B coverage. Additional premiums must be paid to the government to have Part B coverage. Like most insurance, Part B only covers part of the qualified charges leaving 20% or more to be paid by the resident.

VETERANS ADMINISTRATION

The Veterans Administration contracts with some nursing homes to provide for residents covered by the VA program. The facility receives a per diem rate from the VA that covers room, board, and the resident's medical needs. The attending physician is even obtained and paid by the facility.

HEALTH INSURANCE

Most private health insurance policies do not pay for a significant amount of nursing home costs. Coverage is usually limited to convalescence from an acute episode. Insurance policies vary widely and may pay for nothing, some therapies, or room and board for a limited stay. Some programs such as the State Employee's Health Plan may pay for most of the costs.

LONG TERM CARE INSURANCE

Private long term care insurance has played a small but growing role in paying for long term care. Enactment of a federal income tax deduction and a North Carolina income tax credit for long term care insurance premiums are expected to boost the sales of these policies. Purchasers usually choose the amount of benefits paid per day, whether or not the daily benefit amount will be increased over time to cover inflation, the length of the waiting period, and the length of the benefit period. Consumers are advised to check carefully to see what conditions are necessary for benefits to be paid (usually the need for assistance with a number of activities of daily living).

PRIVATE PAY

Payment from the resident's own funds is required if the nursing facility stay is not covered by one of the various insurance programs. The daily rate covers room, board, nursing care, and some other routine items. Additional charges include drugs ordered by physicians, medical supplies, and personal items. The full cost of therapy and special services are billed to the resident unless a portion is covered by Medicare Part B. Unfortunately, private payment for a nursing home stay can result in the depletion of a resident's funds and conversion to Medicaid coverage.

MEDICAID

Medicaid pays for about three-quarters of nursing facility stays in North Carolina. It provides coverage in approved facilities at the level of care Medicaid determines is appropriate. Public assistance is provided when the resident does not have the assets to pay their own expenses. The resident must prove to the Country Department of Social Services that their funds have been depleted. Most of the resident's continuing income, if any, is used to pay expenses, and Medicaid pays the remainder.

OTHER RESOURCES

The following web sites offer additional information on paying for long term care:

WHAT NEXT?

If quality long term care is what you are looking for, a North Carolina nursing home is the place to find it.

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