• What is the Difference Between Traditional Nursing Care and Personal Care?
• Does Medicare Pay for Nursing Home Care?
• Who Pays the Bill for Nursing Home Care?
• What is the Difference between Medicare and Medicaid?
• What if I have an HMO or Managed Care Insurance?
• What is Co-Insurance and Who Pays It?
• What is Medicare Supplemental Insurance?
• How Do I Pick the Right Skilled Nursing Facility?
• What Questions Should I ask at a Skilled Nursing Facility?
• What is the Five-Star Quality Rating System for Skilled Nursing Homes?
• What is a Department of Health Survey?
• How Do Skilled Nursing Facilities Handle Doctor Visits for Residents?
• Who Decides When Residents are Discharged to Home?
• What Happens if a Resident’s Money or Insurance Coverage Runs Out?
• What Happens to a Resident’s Social Security or Pension Income When in a Skilled Nursing Facility?

What is the Difference Between Traditional Nursing Care and Personal Care?

Traditional nursing care offers a wide range of specialized services for individuals with varying health conditions, delivered by skilled professionals.  Both short-term and long-term care is available in traditional nursing, and services may include treatment for cancer, strokes, cardiovascular disease, pulmonary disease or other serious medical conditions.  Short-term rehabilitation care is often provided following an illness, injury or surgery to help patients return to an active, independent lifestyle.

Traditional nursing care generally cares for individuals who are unable to care for themselves with minimal assistance.  Care and services are designed to satisfy residents’ physical, emotional and psychological needs.  Residents typically require assistance with activities of daily living, including dressing, bathing, eating and medication management.  Meals, opportunities for socializing and group activities are provided to residents. 

Traditional nursing care may be paid by Medicare, Medicaid, insurance or private funds, depending on each individual’s needs and financial situation.

Personal care is not an alternative to traditional nursing care; rather, it is an intermediate level of long-term care.  Personal care offers assistance to seniors who are not able to live by themselves, but do not require constant care.  Residents of personal care typically live in apartment-style units, with access to group activities, three prepared meals each day and health care services as needed. Services may include tasks such as meal preparation, housekeeping, and assistance with bathing or dressing.

Personal care is not typically paid for by Medicare, Medicaid or insurance. Most personal care residents pay privately for services.

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Does Medicare Pay for Nursing Home Care?

Medicare, the medical insurance for individuals age 65 and older or those receiving Social Security disability coverage, accounts for only 11 percent of skilled nursing costs. Medicare does not pay for long-term nursing care. On average, Medicare pays for 3 to 4 weeks of care.

In order for Medicare to pay for skilled nursing care, the individual:

• Must need skilled services (such as a Registered Nurse for IV medication or a Physical Therapist every day)
• Must have had a minimum 3-day hospital stay that requires additional skilled services, according to a physician

Medicare coverage ends when the individual:

• No longer needs skilled services (such as an IV)
• Returns to same level of health before the illness/injury
• No longer shows improvement

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Who Pays the Bill for Nursing Home Care?

On average, nursing home stays are paid for by:

• Medicaid (the payment source for people without enough money to pay for themselves): 64%
• Medicare: 11%
• Private insurance, such as a Health Maintenance Organization (HMO), or private funds: 25%

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What is the Difference between Medicare and Medicaid?

Medicare is a federally funded program for individuals who are over the age of 65 or who are disabled. Medicare A, which covers inpatient care, pays for skilled care for a maximum of 100 days per illness. The first 20 days of nursing care are fully covered. Although most individuals do not remain under skilled care for the entire 100 days, the resident is responsible for a daily co-insurance charge after day 21. Under certain limited conditions, Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, individuals must receive the services from a Medicare certified Skilled Nursing Facility following a qualifying hospital stay (at least 3 days).

Medicaid, or Medical Assistance, is a state and federally funded program for adults who need medical care and have limited income or funds to pay for it. Individuals must qualify medically and financially for Medicaid to pay for Skilled Nursing Facility services. Medicaid will pay only for skilled nursing care provided in a facility certified by the government to service Medicaid recipients. Not all Nursing Homes accept Medicaid payments. There is no limit to the amount of time that Medicaid will pay for skilled nursing care; however, there is an annual review to make sure that the individual continues to be eligible for the program.

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What if I have an HMO or Managed Care Insurance?

HMOs and Managed Care Companies are private insurance companies. Each insurance company has individual definitions and coverage terms. The insurance company decides what is covered and how long it will be covered. They generally follow the same skilled care requirements as Medicare. Pre-authorization, or approval prior to admission, is needed in order for the insurance company to cover the cost of Skilled Nursing Facility services. The insurance company will inform the individual when services are no longer covered. HMOs do not pay for long-term care.

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What is Co-Insurance and Who Pays It?

Co-insurance charges are the amount that the individual must pay privately toward the cost of care.  Medicare and most HMOs have co-insurance. Medicare Co-Insurance begins on the 21^st day of care.

Some individuals also have Medicare Supplemental Insurance policies, which usually pay for co-insurance charges. Each HMO policy may be different, with many co-insurance fees beginning on the 8^th day of care. It is important to check individual coverage at time of admission to a skilled nursing facility. Individuals who are approved for Medicaid benefits are not responsible for co-insurance charges.

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What is Medicare Supplemental Insurance?

Medicare Supplemental Insurance is private insurance. It is often called Medigap because it helps pay for gaps in Medicare coverage, such as deductibles and co-insurance. Most Medigap plans will help pay for skilled nursing care, but only when that care is covered by Medicare. Additionally, some people use Long-Term Care Insurance to help cover skilled nursing costs.

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How Do I Pick the Right Skilled Nursing Facility?

Just as each individual’s needs are different, each Skilled Nursing Facility is different. It is crucial to research your options to determine the facility that will best meet your needs. The most important step in choosing the right facility is to visit the facility, take a tour and meet the staff.

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What Questions Should I ask at a Skilled Nursing Facility?

The Medicare website offers guides and resources for comparing skilled nursing facilities to assist you in the decision-making process.  The Pennsylvania Department of Health also provides a checklist for your reference: Nursing Home Check List.

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What is the Five-Star Quality Rating System for Skilled Nursing Homes?

The Five-Star Quality Rating System was created to help individuals, their families and caregivers compare skilled nursing facilities. This rating system is based on data from three areas: Health Inspections, Staffing and Quality Measures. The Centers for Medicare and Medicaid Services (CMS) provide a star rating for each of these three areas. Then, these three ratings are combined to calculate an overall rating.

Reviewing health inspection results, staffing data and quality measure data are three ways to measure overall quality. This information gives you a “snap shot” of the type of care provided by skilled nursing facilities; however, there is some conflict regarding the accuracy and effectiveness of the Five-Star Quality Rating System.

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What is a Department of Health Survey?

Skilled Nursing Facilities are reviewed at least yearly by representatives of the Department of Health to determine if the facility is providing quality care and meets the requirements to receive Medicare or Medicaid payments. The survey is an unannounced visit and lasts several days. The review includes facility tours, general nursing care, medical record review, resident and family interviews, staff ratios, housekeeping, food service, nutrition, social services and general facility operations. The facility receives a report of any area that requires improvement and is provided with a short period of time to make corrections.

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How Do Skilled Nursing Facilities Handle Doctor Visits for Residents?

Individuals in Skilled Nursing Facilities must be seen by a physician within a few days of admission and again every 30 days, for the first 90 days. After 90 days, the individual must be seen by a physician at least every 60 days. More frequent visits may be needed based on the individual’s medical needs. Most facilities have a panel of physicians who provide services at the facility. The physicians are often not employed by the facility, but have privileges to see patients there. Each individual or their family may select the physician of choice from the panel or will be assigned the next available physician.

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Who Decides When Residents are Discharged to Home?

Generally, decisions regarding discharge are made jointly by the physician and the individual, as well as his/her family members. Facility social workers will discuss discharge plans during the stay and will help individuals prepare for home, transfer to a lower level of care (such as personal care), or transfer to long-term care. Ultimately, the decision to discharge is made by the individual, as each person has the right to make his/her own decisions. In the event that the individual is unable to make decisions due to a medical condition, his/her responsible party would make the final decision.

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What Happens if a Resident’s Money or Insurance Coverage Runs Out?

If the facility accepts Medicaid, individuals who run out of money or no longer have insurance coverage may apply for benefits under the Medicaid program to remain at the skilled nursing facility. A representative from the Department of Public Welfare will review the application and decide if the individual qualifies medically and financially for a Medicaid Nursing Home Grant. If the application is denied, the individual is responsible for the skilled nursing facility costs. If the application is approved, Medicaid covers the costs. If the skilled nursing facility does not accept Medicaid, the individual will need to move to a new facility that does accept Medicaid.

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What Happens to a Resident’s Social Security or Pension Income When in a Skilled Nursing Facility?

If the costs are being paid by Medicare, insurance or with private funds, the individual continues to receive Social Security or pension income and can use the funds the same way as he/she always has. If the costs are being paid under Medicaid, the individual is usually required to help pay for the care using the Social Security and pension income. There is an exception if the individual has a spouse living in the community; the Department of Public Welfare decides if the spouse in the community needs to keep some or all of the funds to maintain a home.

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