This portion of the Medicare program must be purchased through a deduction from your Social Security earnings. You will know the coverage is in force if the words “Medical Insurance” are typed on your Medicare card.
What services does this type of coverage pay for?
- Physician services
- Ambulance Services
- Laboratory Services
- Physical, occupational and speech therapies
What am I eligible for if I have this type of coverage?
The Medicare program under Part B pays 80% of reasonable charges for the above services. The person is responsible for 20% of the bill plus the values of the annual deductible, if not previously paid.
Eligibility is determined by resources, income and medical necessity. Medicaid assists eligible patients with the monthly cost in a nursing home for both skilled and intermediate care. The patient’s monthly income minus $72.80 per month for personal use, is applied to the monthly cost of the nursing home. A spouse is also allowed to keep the monthly cost of a health insurance premium. Medicaid adds to the amount the patient has as income, to reach the total amount required by the nursing home.
Resources and Medicaid
What resources can I have and still be eligible for Medicaid?
The resources of a person applying for Medicaid as well as their spouse are considered. The spouse who remains at home, may keep a minimum of $1,999.00 of the resources or one half, whichever is greater. The maximum kept cannot exceed $110,000
How does Medicaid define resources?
Resources are defined as cash money and any other personal or real property that person or couple owns. Resources may include, but are not limited to:
- checking accounts
- stocks & bonds
- certificates of deposit
- burial reserves
- life insurance policies
- savings account
What resources are exempt and not considered in the Medicaid eligibility determination
- $2,000 (for use by the nursing home resident).
- The individual’s home if the applicant has been in a nursing home less than six months or if the home is occupied by a spouse, dependent or disabled child, or a sibling with an equity interest who has lived in it for at least a year.
- One vehicle, regardless of value.
- The cash surrender value of the nursing home resident’s life insurance policies if the face values of all policies total $2,000 or less.
- An irrevocable pre-burial contract and burial plot.
- A trust established by will or someone other than the nursing home resident or spouse
- Any resource not available to the nursing home resident
When can Medicaid coverage be jeopardized?
If resources are transferred 60 months or less prior to the Medicaid eligibility application month, it is presumed that the transfer of resources was for the sole purpose of establishing Medicaid eligibility. The Department of Human Services does investigate transferred resources. If the transferred resources are found, approval for Medicaid benefits could be jeopardized. Income The monthly income of the person applying for Medicaid may not exceed the cost of one month in a nursing home. Income is defined as money received from statutory benefits, (social security, VA pension, Black Lung benefits, and Railroad Retirement benefits), pension plans, rental property, investments or wages for labor or services.
What documents are necessary when applying for Medicaid?
- Social Security Card
- Medicare Claim Card
- Health Insurance Card-the amount of the premium and method of payment.
- Verification of Income-a copy of your monthly check.
- Bank statements-from the three months preceding the present month.
- Records of Other Accounts – bank record of Certificates of Deposit or other special accounts.
- Life Insurance Policies.
- Burial Policies – copy of the policy and cash value.
- Birth Certificate or proof of birth.
- Other documents, if applicable- marriage certificate, proof of mortgage, etc.
Some insurance plans may cover a portion of nursing home costs. Your policy will indicate the extent of your coverage or you may wish to call your insurance agent or company benefits manager to discuss details. The social worker can assist if you are uncertain about whom to contact.
Will the nursing home bill me or the insurance company?
Some nursing homes will not bill private insurance companies directly, but ask for payment from the patient. Reimbursement is provided to the patient from the insurance company.
Personal Funds/Private Pay
If you do not qualify for Medicare/Medicaid benefits, you may enter any nursing home on a private pay basis. If you intend to pay privately for nursing home care, please notify the social worker who will assist you with transfer arrangements.
Long Term Care Insurance
Long-term care insurance can be purchased to cover the cost of a nursing home and occasionally home health care not covered by the Medicare program. Policies are sold individually as well as through employers. Since most nursing home patients need custodial rather than skilled care, (usually covered by Medicare), long term care insurance can be a good buy depending upon the particular policy and the age of the insured. Policies may vary by restrictions, type of care, method of payment and length of coverage, making them difficult to compare.