ADDITIONAL RESOURCESFor many seniors, the differences between Medicare and Medicaid can be very confusing.
Medicare Program: Medicare is the government health insurance program for people over 65 and for those on Social Security disability. Medicare provides coverage for hospitalization, doctors and other types of medical expenses. Medicare is a medical insurance program; it is not coverage for nursing home or other long-term care. However, if you took a survey, you’d find that many people are convinced that Medicare covers long-term nursing home costs. Unfortunately, that is not the case.
Although Medicare does not cover long-term care, it does have a limited short-term benefit, typically for rehabilitation purposes. In order to get Medicare coverage for a short-term nursing home stay, you must not only be in a Medicare-approved skilled nursing facility, but you must have first been in the hospital for at least three days prior to entering the facility. In addition, you must be “medically benefiting” from that skilled nursing, according to Medicare standards.
Technically, there is a maximum of 100 days of nursing home benefit. In actual practice, the requirement about medically benefiting usually limits the benefit to a period of 20 to 30 days for rehabilitation. For example, you have a stroke and go to the hospital. You spend a few days in the hospital to take care of the immediate medical emergency and then, since you are no longer in danger, you can be transferred to a skilled nursing facility in order to receive rehabilitation services. Again, that is typically going to be in the range of 20 to 30 days.
At the point where your rehabilitation plateaus (you stop improving); you are unable or unwilling to cooperate with the rehab regimen, or, in rare instances, you reach the 100-day limit, you will then lose your Medicare coverage, as far as the nursing home bill is concerned. Except for this limited benefit, Medicare does not pay for nursing home care. You are now on your own. You may still be in a situation where you have to be in a nursing home, even skilled nursing, but you no longer qualify for Medicare to cover your nursing home care. Of course, if you hadn’t spent at least three days in the hospital prior to being admitted to the nursing home, you would not have qualified for Medicare in the first place. From the very first day in the nursing home, you would have been on private pay. And under no circumstances does Medicare pay for assisted living, residential care facilities, adult foster care or in-home care. Medicare does have benefits for home health, but this is purely for medical reasons, not for caregivers to come in and attend to someone who needs help with their personal needs.
Medicaid Program: If a person is able to qualify for Medicaid, what kind of services and benefits can be provided? In Oregon, Medicaid will cover long-term nursing home care. In fact, that's what the Federal program was intended to cover - nursing home care. In addition, Medicaid will generally cover other necessary expenses, such as medical costs, prescriptions, supplies and other medically necessary medical expenses not otherwise covered by Medicare or your medical insurance.
In addition, Oregon has applied to the Federal government for waivers to allow them to use this money for other types of care, or care in different settings. Oregon Medicaid not only covers a nursing home stay, but also assisted living, adult foster care, group homes, residential care facilities and even in-home care.
Another requirement you need to be aware of is that even if a particular type of facility is covered under Oregon's Medicaid program, the specific facility the patient is in has to have a Medicaid contract. A facility that has no Medicaid contract cannot accept Medicaid payments for their services. In the case of nursing homes, there are facilities that accept Medicare, there are nursing homes that will accept both Medicare and Medicaid, and there are nursing homes that are private pay only. The great bulk of nursing homes accept Medicaid, but you need to find that out before admitting the patient into care. Regardless of the type of facility you’re considering, the first step is to determine whether or not that facility has a Medicaid contract.
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We welcome the opportunity to assist you and your family members by addressing and solving your Medicaid qualification and asset protection needs. Call us now for more information 541-479-2415.
At The Financial Aid Center is a Medicaid planning and consulting firm serving senior citizens and their families throughout Oregon. As Oregon’s premier Nursing Home Medicaid experts, we specialize exclusively in Medicaid eligibility resulting in asset protection and preservation. With our decades of experience we understand the unique individual needs of Medicaid applicants and their families. And over the years we have saved countless families millions of dollars. Simply put, we get the job done.
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The Financial Aid Center
531 NE 'E' Street, Unit B
Grants Pass, OR 97526