Understanding Medicare and Medicaid Coverage for a Skilled Nursing Facility

Most people agree that trying to understand the difference between Medicare and Medicaid is complicated on its own. But when an unexpected life event forces the immediate need for long-term care for a loved one, making sense of coverage options can be even more confusing. If you have found yourself in this position, keep reading because this explanation can help you make sense of a confusing system. You’ll understand the differences between these government programs and whether a private pay skilled nursing facility may be the better fit for your aged parent.

Medicare Basics

Most seniors have some form of Medicare coverage. This federal program does offer coverage for skilled nursing facilities, but it requires both a doctor’s order as well as a three-day inpatient stay before coverage can begin. It is also not intended to be a solution for long-term care because it only covers up to one hundred days of care in a stretch.

In addition, there are clinical qualifiers that are sometimes hard to achieve. The highest percentage of patients who receive Medicare benefits only qualify for those benefits for less than 40-50 days.

If your loved one has any lapse in skilled care, such as a re-admission to the hospital, they may not be covered if they return to the nursing home. In fact, they may even lose their bed while gone because Medicare does not pay to hold their space.

Facts about Medicaid

Medicaid is also federally funded, but it is administered through each state, which means that benefits can vary depending on where you live. Unlike Medicare, Medicaid recipients must demonstrate financial need, and it can also continue to cover long term care as long as a senior meets eligibility criteria.

A number of residents may begin their long term care as private pay but then may switch to Medicaid after they have depleted their assets. However, they may have to change rooms or even facilities when they make that switch. Some states may recoup their expenses through estate recovery after the recipient passes away.

The Advantage of a Private Funds for Use in a Skilled Nursing Facility

As we have mentioned previously in this article, Medicare coverage may only last a couple of weeks in a skilled nursing facility. Medicare cannot be viewed as a funding source that can sustain a person for a long period of time in a facility.

An important fact that the public generally does not know is that Medicaid payments to a New York State skilled nursing facility generally fall far below its actual break-even cost of doing business. This makes it very difficult for a potential patient to gain admission to a nursing facility without some level of private funding.

With both Medicare and Medicaid, your loved one can receive the basics offered by a skilled nursing facility. They should not expect a private room or other amenities to make them more comfortable.

Long Term Care Insurance coupled with some level of private funding is really the best way of assuring entrance to the facility of choice. With this type of payment source, the patient can select any size room and enjoy the options of selecting many amenities that a particular home might offer. The Maplewood strives to provide the kind of environment that feels like home for your loved one. Please call us at 585.872.1800 to learn more about our philosophy or take a virtual tour of our skilled nursing facility.