Medicare Vs. Medicaid: Who Pays Nursing Home Fees in 2023?

Over 80 million Americans are insured by government-sponsored health plans. According to the CDC, there are an estimated 1.3 million nursing home residents. As we approach Medicare open enrollment, understanding the types of elderly care offered by both Medicare and Medicaid is more important than ever. Benefits and coverage vary every year, so don't miss out on the latest updates.

Key takeaways:
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    Medicaid covers some of the costs of nursing home care in a licensed Medicaid facility when medically necessary.
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    Nursing home care is typically not covered by Medicare if that’s the only type of care needed.
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    Medicare open enrollment is from October 15th to December 7th, and January 1st to March 31st for Medicare Advantage plans.

The difference between Medicare and Medicaid

Medicare is caring for the elderly. Medicare is primarily for those over 65, or individuals with a disability. It’s an insurance program that people have paid into and is run by the federal government.

Medicaid is an aid for those in need. Medicaid is an assistance program for those in need of every age, including children. Individuals on a Medicaid program may pay nothing for their healthcare, or a small co-pay. Unlike Medicare, Medicaid is a federal-state-run program, so programs may vary depending on your state of residence.

Medicare and Medicaid have several similarities, as they are both government programs. They are run through a regulatory body called the Centers for Medicare & Medicaid Services (CMS). However, Medicare has 4 “parts”, referred to as parts A, B, C, and D. Each of these plans covers different elements of healthcare.

Medicare partCoverageExamples
Part AInpatient/hospitalHospital care, home health, hospice, and surgery
Part BOutpatient/MedicalOutpatient care, durable medical devices, and preventative care
Part CMedicare AdvantagePrivate plan option that bundles other Medicare coverage. Often includes vision, hearing, and dental
Part DMedicationsPrescription drugs and vaccines

Part A is most relevant when looking into benefits involving nursing homes and long-term care. You may opt for Medicare parts separately, or enroll in a Medicare Advantage plan that bundles the other options. Part D may not be needed if you get drug coverage through Part C, but if you end up wanting Part D coverage later on and join late, you may pay a late enrollment penalty.

What is nursing home care?

Understanding the differences between types of elder care is important when determining which plan is the best choice. When people think of nursing home care, they may be referring to one of the following.

Hospice

Hospice is a type of palliative (comfort) care offered for the terminally ill. To qualify for this, a medical provider must determine that the life expectancy of the patient is around 6 months or less. The patient must consent to be on hospice care, and the medical provider must agree with this plan of care. Hospice may take place at home, inpatient, or outpatient depending on the medical situation.

Custodial care

Nursing home care is often referred to as ‘custodial care’. This type of care offers help for patients that need assistance with activities of daily living, such as dressing, grooming, eating, and mobility. Patients in long-term facilities receive most of their medical care off-site, and medical providers are not usually present in the facility.

Skilled nursing facilities

Skills nursing facilities (SNFs) are usually for patients transferred from an inpatient setting. These patients require medical care to heal from acute conditions. An SNF facility has nurses, nursing assistants, medical providers, and therapists (physical, occupational, and speech). Most patients stay short-term, but there are cases where chronically ill patients need skilled nursing care long-term.

Nursing home Medicare coverage

Nursing home (custodial) care is not covered by Medicare if that’s the only type of care needed. Medicare may cover some SNF care if it’s medically necessary to have skilled nursing care (like injections, dressing changes, IV lines, etc.).

Medicare will cover SNF care based on eligibility requirements. The patient must have Part A coverage, it must be within the covered benefit period, and it must be directly following a qualifying inpatient stay. The care needs also to take place in a Medicare-certified SNF to ensure that CMS requirements are met. Medicare patients are usually still responsible for some of the overall cost as part of their deductibles and coinsurance.

For example, Jean is a Medicare-insured 85-year-old female. She had a kidney infection several weeks ago. Jean was originally admitted to the hospital and discharged after 4 days. She was discharged with a urinary catheter and ongoing IV antibiotics.

Jean’s hospital stay was determined to be a qualified inpatient stay with Medicare because she stayed at least 3 calendar days, not counting her day of discharge. In this case, Jean had coverage to stay in a Medicare-certified SNF. This is because it was following a hospital admission and she needed skilled nursing for catheter care and antibiotic administration. She can stay in the SNF until she no longer has skilled nursing needs.

Nursing home Medicaid coverage

Medicaid covers nursing home (custodial) care that takes place in a licensed Medicaid Nursing Facility (NF). Nursing home residents may need to pay for some of the costs of the nursing home related to personal preferences (like a private room or specially prepared meals).

For example, Robert is an 85-year-old male that lives alone. He is mentally alert and oriented. Robert only takes a few oral medications and remembers to take them. He has trouble cooking for himself, and transferring from his bed to his wheelchair

Robert does not have any skilled nursing needs and only requires custodial care. Medicare would not cover this type of care, so Robert needs Medicaid coverage. If Robert is eligible for Medicaid, this service would be covered. Robert may also purchase private long-term care insurance or look into in-home custodial care if custodial care is his primary coverage concern.

What Medicare programs are available?

Special Needs Plan (SNP)

A SNP is a Medicare Advantage plan that serves people with unique healthcare needs. Members must have a specific type of chronic condition, reside at a care facility, or be eligible for both Medicare and Medicaid. The plan is catered to the services that the member needs, so it may provide benefits that a regular plan won’t.

Program of All-Inclusive Care for the Elderly (PACE)

The PACE program is run by both Medicare and Medicaid for the elderly. The medical and social care provided by PACE is designed to keep the elderly out of nursing homes. This is ideal for patients that qualify for nursing home care but can safely live in the community. Members must be 55 years or older to receive this benefit.

Medigap

Private insurance is meant to cover costs that Medicare doesn’t cover, like coinsurance or deductibles. Some Medigap plans will also cover the cost of healthcare during international travel. Medigap plans aren’t compatible with Medicare Advantage plans, so you must choose one or the other. Typically, Medigap doesn’t cover long-term care or private-duty nursing.

Don’t miss Medicare open enrollment

If you or a family member needs elderly care, make sure to take a look at your available healthcare plans to learn more about coverage of nursing homes, skilled nursing, and hospice.

Medicare open enrollment is from October 15th to December 7th, and open enrollment for Medicare Advantage plans is from January 1st to March 31st. Medicaid does not have enrollment periods and qualified individuals can sign up at any time. If you’re already enrolled in Medicare, make sure you log in to compare plans this year and make note of any upcoming changes to your current plan.

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