Types of Insurance
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Assistance Resources

Nursing Homes

Medicare
The state oversees nursing home licenses and has a contract with Centers for Medicare and Medicaid Services. Nursing homes that accept Medicare and Medical Assistance are regularly inspected.

Under Part A:
In order for a person to receive nursing home benefits under Medicare, the following criteria must be met:

• a three-day hospital stay in the previous thirty days
• need for continuous skilled nursing care
• receive care from a qualified doctor

For those qualifying for coverage under Medicare, nursing home care is covered for 100 days as long as the person continues to require skilled nursing care. The first 20 days are covered in full and 20 percent co-pay is required from the 21st day to the 100th day of nursing home care. There is no Medicare coverage after the first 100 days, until a new benefit period begins based on the qualifying criteria noted above.

Under Part B:
A limited number of nursing home services are covered under Medicare Part B, which may include doctor services, specialized tests and equipment, renal dialysis, blood transfusion, emergency transport to the hospital or the emergency department of a hospital. This coverage continues for a person who may have either exhausted all of Part A services or do not qualify for Part A services, while staying in a nursing home.

For Long-term Specialty Care in Nursing Homes:
The criteria for coverage under Medicare, Medical Assistance and Managed Care remains the same for a person with Alzheimer's Diseases as any other person requiring nursing home care.

Any individual in a nursing home with an end-of-life condition may opt for Hospice care under the Medicare program. When a person opts for Hospice benefits, traditional Medicare benefits are available only for unrelated conditions. The person will receive all Hospice benefits, except for room and board, which must be paid privately. If a person opting for Hospice benefits is also on Medical Assistance, then Medical Assistance will cover room and board, while the other benefits will be covered by the Hospice benefit.

Medigap
In addition to Medicare Part A and Part B, many older adults also purchase a Medigap policy. Many commercial providers including AARP offer these policies.

These policies cover many co-payments, deductibles and non-covered services such as pharmacy services. A Medigap policy is not needed, if a person decides to join an HMO as most of the HMOs have pharmacy coverage and small co-payments or deductibles.

Medigap may cover some of the long-term care co-payments and deductibles, but it is not a Long-term care insurance policy.

Additional information about Medigap policies is available through the Pennsylvania Agencies on Aging's APPRISE counselors.

Medical Assistance
This is the largest payer of nursing home care in the country.

In order for elderly to qualify for Medical Assistance, they must meet the income criteria set by the Pennsylvania Department of Public Welfare (DPW). A person over 65 years of age may qualify for Medicare as well as Medical Assistance, and have dual benefits. Medicare and DPW have implemented many "waiver programs" to delay nursing home placement and reduce the health care expenditure incurred by the dual benefits.

Medical Assistance reimbursement is all-inclusive just like Medicare.

An individual must be assessed by the Pennsylvania Area Agencies on Aging (AAA) to determine if the person is eligible for nursing home placement. This assessment is referred to as the "OPTIONS Assessment." Once a person is deemed eligible for nursing home care, he is eligible to receive nursing home care indefinitely.

A facility must be licensed by Department of Public Welfare (DPW) to provide nursing home care to Medical Assistance (MA) recipients. All the beds in a facility must be licensed for Medical Assistance.

Commercial Insurance
Commercial insurance companies may have provisions for nursing home care.

Managed Care
Managed care insurance companies identify their “network” health systems; contact their representatives to discuss how that may impact reimbursement. Managed Care: Medicare and Medical Assistance require that the benefits provided under the HMOs for their beneficiaries must be equal or greater than covered under traditional Medicare or Medical Assistance. The benefits remain the same with minor variations from one HMO to the other. Under the mandated Medical Assistance managed care in Western Pennsylvania, a patient in a nursing home reverts back to traditional Medical Assistance after the first thirty days of nursing home care.

Long-term Care Insurance
Most long-term care insurance policies may cover nursing home care, either after Medicare coverage has been exhausted or it fill the gaps where Medicare coverage is unavailable. The benefits vary depending upon the policy.

U.S. Veterans Benefits
U.S. Veterans Benefits may provide coverage for nursing homes. Call 877-222-8387 or visit http://www.va.gov/health_benefits/ for more information.

Your Out-of-Pocket Costs
Nearly half of nursing home care is covered privately by individuals, families and private organizations providing benevolent care.

These may include room and board, pharmacy, private sitters, many medical supplies and assistive equipment, nourishments, supplements, and more.