What You Need to Know About Medical Assistance Coverage in Long Term Care

Elan Skilled Nursing and Rehab Explains

Navigating the payment options available to pay for nursing home care requires the assistance of those with in-depth knowledge of the industry.  Understanding what options are available, qualifications required, and the services covered is critical when you or a loved one needs nursing home care.  At Elan Skilled Nursing and Rehab, our team of experts is available to advise and assist you with understanding the avenues available to you when considering nursing home care.

Long-Term Care (“nursing home care”) is mainly paid for through personal funds, government programs, and third party insurance.  Medicare and third party insurance payment options require certain qualifications depending on the type of care and services an individual medically requires.  These insurers only pay for brief periods of nursing home stays.  Most typically, individuals who need a short stay for acute nursing or therapy services in order to safely return home.

The challenge for many individuals is identifying payment options when the care being provided doesn’t meet the qualifications of Medicare and third party insurance programs.  In these instances, an individual will be expected to pay privately from their own funds, such as checking and savings accounts, annuities, and trusts.  Some life insurance policies maintain a cash value and may be used to fund care.  Long-Term Care insurance is another option that may provide a nursing home benefit.  Each insurance policy is different so it is important to keep your plan documents in an easily retrievable place in the event it is needed.

Individuals who do not have the resources to pay privately for nursing home care may qualify for Medical Assistance (“Medicaid”) Long Term Care Benefits if they meet the program’s financial and medical requirements.

In fact, Medicaid pays for the largest share of long-term care services, but to qualify, one must be both financially and medically qualified.

Clinical Eligibility

Your physician must determine and certify that you are considered Nursing Facility Clinically Eligible (NFCE) in Pennsylvania.  There are four criteria that must be met to be considered eligible.

  1. The individual must have an illness, injury, disability or medical condition diagnosed by a physician; and
  2. As a result of that diagnosed issue, the individual requires more care and services than room and board; and
  3. A physician certifies the individual as Nursing Facility Clinically Eligible; and
  4. The individual requires health related care and services that are necessary on a regular basis and can only be provided through medical or technical personnel.

The assessment will gather information from a variety of sources, such as health care providers, family members, and through direct observation of the individual in performing activities of daily living.  The assessor will evaluate the individual’s cognitive abilities, physical health status, medication use, available support systems, as well as observe for signs and symptoms of abuse and neglect.

Individuals with serious mental illness or intellectual disability must also be evaluated by the Pre-Admission Screening and Resident Review program, often referred to as the PASRR, to determine if nursing facility admission is needed and appropriate.

Once a level of care determination deems an individual clinically qualified for coverage, financial eligibility must also be determined.

Financial Eligibility

Financial eligibility evaluates two types of resources: assets and income.  Pennsylvania’s Medicaid system determines an individual’s asset and income limits according to the Federal Benefit Rate (FBR).  In 2022, the income limit is $2,523 per month but normally changes on January 1st of each year due to inflation.  In 2023, the income limit is expected to be $2,742 per month. If an unmarried individual’s income is equal to or less than the income limit then their asset limit is $8,000.  If more, then $2,400 in non-exempt assets may be retained.

Assets often include a home, vehicle, checking and savings accounts, bonds, stocks, annuities, and life insurance policies.  Some assets do not count towards an individual’s asset limit for Medicaid eligibility purposes and are considered exempt.  Under certain circumstances, an individual’s home or vehicle may not impact Medicaid eligibility.  Exempt assets may be retained in addition to the non-exempt asset limits.

Some individual’s attempt to liquidate their resources to family and friends prior to applying for benefits.  Transfers of assets for less than fair market value within five years of applying for Medicaid LTC services could affect eligibility.   By gifting assets to children, grandchildren, siblings, and close friends, individuals may disqualify themselves from Medicaid coverage.  For every gift made during the previous five-year period, a penalty period may be assigned, which is the amount of time the individual must wait before they can receive benefits.  Since nursing homes are not required to care for individuals with no source of payment, the individual may need to find alternative care.

In addition to assets, Medicaid considers a person’s monthly income when evaluating eligibility.  Income from any source is typically included.  Examples of income may include employment wages, alimony payments, pension payments, social security income, IRA withdrawals, rental income, and interest and dividends from savings and investments.

Married Couples

Special financial eligibility rules apply to couples where one spouse remains in the community (known as the “community spouse”).  These rules are intended to safeguard the impoverishment of the community spouse when the other spouse lives in the nursing facility (known as the “institutionalized spouse”).  Under the Medicaid spousal provisions, a certain amount of the couple’s combined resources is protected for the spouse living in the community.

Patient Liability

Qualifying for Medicaid to assist with funding long-term care and services is necessary for greater than 60% of our nation’s seniors receiving care in the nursing facility setting.  Once an individual is deemed eligible for Medicaid, the next step is to determine how much that individual is able to contribute towards the cost of his/ her own care.  The Medicaid program determines individual’s contributions based on their gross income once certain protected amounts are accounted for.  An individual is guaranteed a monthly personal needs allowance, medical expenses not covered by the Medicaid program, and other protections if there is a spouse or dependent family living in the community.  Once these items are deducted from the individual’s income, any remaining income is deemed the individual’s contribution and must be used to pay for his/her care in the nursing facility.

Many individuals pay for long term care with their personal funds and eventually spend down their resources where they qualify for Medical Assistance LTC benefits.  These benefits will cover only care and services provided in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility (NF).  At Elan Skilled, we are here to assist you with identifying payment options available to you or your loved one.  We can walk with you to assist you to navigate the process, connect you with the appropriate agencies, and serve as a resource.

If you find yourself or a loved one in need of Long-Term Care, look no further than Elan Skilled Nursing and Rehab, formerly the Jewish Home of Eastern Pennsylvania.

Our experienced nursing team is on duty 24 hours a day along with state-certified nursing assistants that further enhance the care that each resident receives. Our high nurse-to-resident ratio, routine assessments, and wide variety of services foster an environment of resident-centered care that makes the difference.

If you are interested in learning more about how we can support you or someone you love, please contact our admissions team or call us at 570-344-6177 ext. 1151.

Visit us:
1101 Vine St.
Scranton, PA 18510

Call us:
(570) 344-6177